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A REPORT
TO THE
ARIZONA LEGISLATURE
Debra K. Davenport
Auditor General
Behavioral Health
Services’ HB2003
Funding for Adults with
Serious Mental Illness
Performance Audit Division
APRIL • 2004
REPORT NO. 04-03
Performance Audit
The Auditor General is appointed by the Joint Legislative Audit Committee, a bipartisan committee composed of five senators
and five representatives. Her mission is to provide independent and impartial information and specific recommendations to
improve the operations of state and local government entities. To this end, she provides financial audits and accounting servic-es
to the State and political subdivisions, investigates possible misuse of public monies, and conducts performance audits of
school districts, state agencies, and the programs they administer.
The Joint Legislative Audit Committee
Representative John Huppenthal, Chair Senator Robert Blendu, Vice Chair
Representative Tom Boone Senator Gabrielle Giffords
Representative Ken Clark Senator Peter Rios
Representative Ted Downing Senator Thayer Verschoor
Representative Steve Yarbrough Senator Jim Weiers
Representative Jake Flake (ex-officio) Senator Ken Bennett (ex-officio)
Audit Staff
Shan Hays, Manager and Contact Person
Monique Cordova, Team leader Joseph McKersie
Aaron Cook Kristie Waldron
Copies of the Auditor General’s reports are free.
You may request them by contacting us at:
Office of the Auditor General
2910 N. 44th Street, Suite 410 • Phoenix, AZ 85018 • (602) 553-0333
Additionally, many of our reports can be found in electronic format at:
www.auditorgen.state.az.us
2 9 1 0 N O R T H 4 4 t h S T R E E T • S U I T E 4 1 0 • P H O E N I X , A R I Z O N A 8 5 0 1 8 • ( 6 0 2 ) 5 5 3 - 0 3 3 3 • F A X ( 6 0 2 ) 5 5 3 - 0 0 5 1
DEBRA K. DAVENPORT, CPA
AUDITOR GENERAL
STATE OF ARIZONA
OFFICE OF THE
AUDITOR GENERAL
WILLIAM THOMSON
DEPUTY AUDITOR GENERAL
April 26, 2004
Members of the Arizona Legislature
The Honorable Janet Napolitano, Governor
Catherine R. Eden, Ph.D., Director
Arizona Department of Health Services
Transmitted herewith is a report of the Auditor General, a Performance Audit of the Department
of Health Services, Behavioral Health Services’ HB2003 Funding for Adults with Serious Mental
Illness. The report is in response to Laws 2000, Fifth Special Session, Chapter 2, §§1 and 5
which established the funding, and required the Office of the Auditor General to examine the
Department’s success in using the monies to meet agreed-upon performance standards. I am
also transmitting with this report a copy of the Report Highlights for this audit to provide a quick
summary for your convenience.
As outlined in its response, the Department of Health Services agrees with all three findings and
plans to implement or implement in a different manner all of the recommendations.
My staff and I will be pleased to discuss or clarify items in the report.
The report will be released to the public on April 27, 2004.
Sincerely,
Debbie Davenport
Auditor General
Enclosures
The Office of the Auditor General has conducted a performance audit examining the
results of appropriating approximately $42 million in special one-time funding for
services to persons with serious mental illnesses. This funding, known as House Bill
2003 (HB2003) funding, was specifically established in Laws 2000, Fifth Special
Session, Chapter 2, §§1 and 5. This legislation also requires the Office of the Auditor
General to examine the success in using the monies to meet agreed-upon perform-ance
standards.1 The program established by the legislation ends on July 1, 2005,
pursuant to Arizona Revised Statutes §36-503.02.
The money was appropriated to the Department of Health Services to provide hous-ing,
vocational rehabilitation, and other support services to people with schizophre-nia,
delusional disorders, or any of several other conditions. The Department’s
Division of Behavioral Health Services (Division) distributed most of the monies to the
five Regional Behavioral Health Authorities (RBHAs) that administer mental health
programs in the State. To obtain the money, each RBHA had to develop a plan con-sistent
with the Division’s specifications, including a list of performance standards for
evaluating accomplishments. Examples of performance standards include reduction
in symptoms, hospitalization, jail and arrests, and substance abuse. The standards
also include increases in housing stability, safety, social adjustment, recovery, and
vocational participation. As of June 30, 2003, the RBHAs had spent more than 82
percent of the total amount allocated to them. Over 90 percent of the monies spent
as of June 30, 2003, was spent in three main areas: housing (40 percent), intensive
case management (35 percent), and additional rehabilitation services (nearly 16 per-cent).
The remaining monies were spent on RBHA administrative expenditures and
such items or services as vehicles for transporting consumers, expanding evaluation
programs, and videoconferencing equipment for expanding service networks. 2
The Division requires all of the monies to be spent by January 1, 2005. According to
division officials, they plan to conduct an evaluation of the programs that the RBHAs
developed with their HB2003 monies once the RBHAs have spent all of their HB2003
monies.
1 Laws 2000, Fifth Special Session, Chapter 2, §5 also appropriated $20 million for funding children’s behavioral health
services. A separate performance audit of the House Bill 2003 children’s services program was released in December
2002 (Report No. 02-12).
2 The Division and the RBHAs refer to persons receiving services as consumers.
Office of the Auditor General
SUMMARY
page i
Consumers benefited from housing programs (see
pages 13 through 23)
The five RBHAs reported using a total of $13.6 million in HB2003 monies, or approx-imately
40 percent of the total spent as of June 30, 2003, to develop housing and
related programs. Research shows that stable housing is an important factor in a
consumer’s recovery from mental illness, although persons with serious mental ill-ness
commonly cannot attain suitable housing and may lose their homes and
become homeless. Research also shows that people with a serious mental illness
need housing that is coordinated with other support services. Through an intera-gency
agreement, the Arizona Department of Housing helped the RBHAs identify
and acquire properties. In all, the five RBHAs reported they bought or built housing
and apartments on 39 sites in 21 cities around Arizona, and created housing space
for 334 individuals. Two RBHAs—ValueOptions and NARBHA—developed super-vised
housing and independent living options, while the other three RBHAs devel-oped
independent housing options only. This housing will continue to be available
after the HB2003 program ends. Two RBHAs—ValueOptions and PGBHA—also
used part of the monies for programs that help people stay in the housing they
already have.
Consumers who lived in the new housing for at least 6 months improved in their men-tal
health functioning and independence, and reported satisfaction with the housing.1
Specifically, at ValueOptions, consumers made greater gains on several measures of
functioning than consumers on a waiting list for new housing. For example, they
improved in measures of family and living environment, interpersonal relations, sub-stance
abuse, self-care, and feeling and mood. At Excel, consumers made gains
only on the substance abuse measure of functioning. Further, results varied accord-ing
to consumers’ beginning mental health functioning level, with the greatest gains
occurring among ValueOptions consumers who had the most severe dysfunction.
Additionally, consumers at both RBHAs generally either maintained or increased their
level of independence. Finally, most consumers interviewed during the audit report-ed
satisfaction with their new housing.
Since three RBHAs’ new-housing consumers generally had not lived in their homes
long enough to be included in this audit’s analysis, the Division should assess con-sumers’
progress at these RBHAs after their consumers have lived in housing for at
least 6 months. The Division should also determine the housing program’s impact on
hospitalization and arrests. Although these two measures were identified in the
Division’s list of performance standards, auditors could not draw conclusions about
them because they were such rare events among the population examined. Finally,
the Division should work with Excel to determine what outcomes should be expect-ed
for consumers in independent housing, and analyze the impact of Excel’s hous-
State of Arizona
page ii
1 The evaluation time frame spanned approximately 24 months from the first time a consumer moved into HB2003 hous-ing
in February 2001 through January 31, 2003.
ing program against those outcomes. The Division could conduct these analyses as
part of the HB2003 program evaluation that it plans to conduct once all HB2003
monies are expended. The Division should use its research results to develop rec-ommendations
and provide technical assistance to the RBHAs to improve their
housing programs.
Consumers show modest gain from intensive case man-agement
programs (pages 25 through 34)
Four of the five RBHAs reported using $12 million, or 35 percent of total spending as
of June 30, 2003, to develop intensive case management teams to provide con-sumers
with a range of services, including substance abuse and vocational coun-seling,
medication management, and life skills training. The teams differ from tradi-tional
case management in their staffing structure, caseload size, and frequency of
contact. In addition, team members provide many services directly instead of coor-dinating
all services through other providers. Several research studies on Assertive
Community Treatment (ACT), a form of intensive case management, have linked this
approach with fewer hospitalizations, less severe symptoms, and increased life sat-isfaction.
As of December 31, 2002, more than 2,200 consumers, or about 8 percent
of the adults with serious mental illness in the behavioral health system, had received
assistance from the new teams.
Overall, consumers who participated in these new intensive case management pro-grams
made modest improvements in their functioning level, while consumers in a
comparison group either stayed the same or worsened.1 Consumers with more
severe dysfunctions prior to entering the program showed the greatest gains.
Symptoms and hospitalization remained stable for most groups, and self-reported
arrests improved but not as much as expected. However, consumers’ own assess-ments
of their mental health status improved, and consumers interviewed during the
audit told auditors that they felt the new services had helped them. The length of time
consumers remained in the program did not affect functioning level results. Although
the new programs resulted in modest improvement for consumers at most RBHAs,
PGBHA’s consumers showed little change from services provided through HB2003
during the 24-month evaluation time frame. In conjunction with the recommendation
to analyze arrests for consumers who lived in HB2003 housing, the Division should
also analyze arrests for consumers who participated in the intensive case manage-ment
programs, since auditors could assess results for only two of the four RBHAs
that developed these programs. The Division should also evaluate the program’s
impact on length of hospital stay, since discharge data was too limited for auditors
to conduct this analysis. Finally, the Division should examine the causes for the lack
1 The evaluation time frame spanned approximately 24 months from the time of earliest enrollment in February 2001
through January 31, 2003.
Office of the Auditor General
page iii
of significant results for PGBHA’s consumers. The Division could conduct these
analyses as part of its planned program evaluation, and should develop recommen-dations
and provide technical assistance to the RBHAs to improve their intensive
case management programs.
Rehabilitation activities have increased (see pages 35
through 43)
Using $5.4 million in HB2003 monies, or nearly 16 percent of the total spending as
of June 30, 2003, according to their reports, three RBHAs—ValueOptions, CPSA,
and NARBHA—provided greater vocational rehabilitation and recovery support serv-ices
for consumers. These services range from teaching consumers basic commu-nity
living skills to helping them prepare to find and keep a job. RBHAs mainly pur-sued
two strategies for improving rehabilitation and recovery support services:
integrating rehabilitation planning into clinical case management and expanding
rehabilitation service availability in their respective service areas. For example, some
RBHAs have established consumer-run drop-in centers where consumers can meet
to support each other and socialize, volunteer, work, and actually oversee operations.
The Rehabilitation Services Administration (RSA) of Arizona’s Department of
Economic Security has also been involved in these efforts. For example, two RBHAs
are working with the Division and RSA to teach consumers recovery principles and
help them find employment as peer support specialists.
As a result of these efforts, consumers in two RBHAs increased their involvement in
some types of meaningful community activities.1 Consumers at ValueOptions
increased their involvement in psychosocial rehabilitation and consumer-run activi-ties.
Some consumers at ValueOptions and CPSA-5 who were involved in those
activities improved their interpersonal relations functioning. In addition, ValueOptions
and CPSA-5 consumers increased participation in education, training, and transi-tional
work activities. However, most consumers showed little or no increased partic-ipation
in paid employment. Research on the employment of persons with serious
mental illness states that if competitive employment is the ultimate goal, then reha-bilitation
efforts should be directly focused on competitive employment to achieve a
successful outcome. According to the Division, the HB2003 programs focused pri-marily
on those individuals who were not expressing an immediate desire to enter the
workforce, and emphasized getting people involved in any meaningful rehabilitation
activity, rather than focusing exclusively on paid employment.
The Division should analyze rehabilitation activity levels at a later date to determine if
ValueOptions and CPSA consumers continue to increase their activity levels, and
whether the other RBHAs’ consumers eventually increase their activity levels. The
Division could do this as part of its planned program evaluation, and should provide
1 The evaluation time frame for rehabilitation services spanned 20 months from June 1, 2001 through January 31, 2003.
Auditors used a shorter time frame to control for the effect of a data conversion that occurred in April 2001 that changed
the way the RBHAs reported rehabilitation status.
State of Arizona
page iv
technical assistance to the RBHAs to identify and implement any needed program
changes to increase activity levels in the different geographic service areas.
According to division and RBHA representatives, most of the HB2003 rehabilitation
system enhancements will be sustainable in the future because they have been
added as covered services under Medicaid. This change took place in October
2001. HB2003 monies were used to help service providers set up systems to report
these services to the RBHAs and pay for services for persons who are not Medicaid-eligible.
Office of the Auditor General
page v
State of Arizona
page vi
Office of the Auditor General
TABLE OF CONTENTS
continued
page vii
1
13
13
15
17
21
23
25
25
27
32
33
34
35
35
36
39
43
43
Introduction & Background
Finding 1: Consumers benefited from housing
programs
Housing important for consumers with serious mental illness
Housing and housing support provided
Consumers benefit from housing programs
Programs appear well-designed and help address housing gap
Recommendations
Finding 2: Consumers show modest gain from
intensive case management programs
Intensive case management teams developed
New case management programs benefit consumers
Program design has some elements of successful models
RBHAs plan to continue programs
Recommendations
Finding 3: Rehabilitation activities have increased
Rehabilitation services cover a broad spectrum and involve two
agencies
RBHAs integrate and expand services
Some participation in meaningful activities increased
Covered Services Project will help sustain services
Recommendation
State of Arizona
TABLE OF CONTENTS
page viii
Appendix 1:
HB2003 Performance Measures
Appendix 2:
Summary
Design and methods
Appendix 3:
Bibliography
Agency Response
Figures:
1 Regional Behavioral Health Authorities
Program Fund Allocations
Through June 30, 2005
2 House Bill 2003 Housing Locations by
Regional Behavioral Health Authorities
As of June 30, 2003
3 Rehabilitation Activity Levels
Before and After Consumers’ Participation
in HB2003 Programs
June 1, 2001 through January 31, 2003
a-i
a-vii
a-vii
a-ix
a-ix
a-xxxix
a-xlv
4
15
42
continued
Office of the Auditor General
TABLE OF CONTENTS
continued
page ix
5
6
8
16
18
27
28
a-xv
Tables:
1 Performance Measures
for Evaluating Outcomes of
HB2003 Programs for Adults with Serious Mental Illness
2 HB2003 Serious Mental Illness (SMI) Program Allocations
and Expenditures
From Program Inception through June 30, 2003
(Unaudited)
3 Number of HB2003 Consumers with a Serious Mental Illness
Served
As of December 31, 2002
4 Number of HB2003 Housing Consumers by RBHA
February 1, 2001 through September 30, 2003
5 Housing
Progress of HB2003 Housing Consumers
and Two Comparison Groups
by Performance Measure
July 1, 2000 through January 31, 2003
6 Consumers Served by RBHAs’
Intensive Case Management Teams
As of December 31, 2002
7 Progress of HB2003 Intensive Case Management
and Comparison Group
by Performance Measure
July 1, 2000 through January 31, 2003
8 Housing
Average ALFA Scores for Three RBHAs
Before and After Residence in HB2003 Housing
July 1, 2000 through January 31, 2003
State of Arizona
TABLE OF CONTENTS
page x
Tables (cont’d):
9 Housing
Differences in Average ALFA Scores for Two RBHAs
July 1, 2000 through January 31, 2003
10 Housing
Comparison of Average ALFA Changes for HB2003 Consumers
and ValueOptions’ Waiting List Consumers
July 1, 2000 through January 31, 2003
11 Housing
Differences of Average CGI Scores for HB2003 Consumers at
Three RBHAs Compared to ValueOptions’ Waiting List Consumers
July 1, 2000 through January 31, 2003
12 Housing
Differences of Average CGI Scores for HB2003
Consumers at Two RBHAs
July 1, 2000 through January 31, 2003
13 Case Management
Differences in Average ALFA Scores
Before and After Participation
in HB2003 Case Management Teams
July 1, 2000 through January 31, 2003
14 Case Management
Differences in Average ALFA Scores for Four RBHAs
July 1, 2000 through January 31, 2003
a-xvi
a-xvii
a-xviii
a-xix
a-xx
xxi
continued
Office of the Auditor General
TABLE OF CONTENTS
continued
page xi
a-xxii
a-xxiii
a-xxiv
a-xxv
a-xxvi
Tables (cont’d):
15 Case Management
Differences in Average ALFA Scores
for ValueOptions’ HB2003 High-Intensity, Community-Based
Team Consumers Compared to Other ValueOptions’ Consumers
July 1, 2000 through January 31, 2003
16 Case Management
Differences of Average CGI Scores
for HB2003 Consumers at Four RBHAs
July 1, 2000 through January 31, 2003
17 Case Management
Differences in Average CGI Scores for ValueOptions’
HB2003 High-Intensity, Community-Based Team Consumers
Compared to Other ValueOptions Consumers
July 1, 2000 through January 31, 2003
18 Case Management
Differences in Average MCS-12 Scores
Before and After Participation
in HB2003 Case Management Teams
July 1, 2000 through January 31, 2003
19 Case Management
Differences in Average SF-12 Scores for ValueOptions’ HB2003
High-Intensity, Community-Based Team Consumers Compared
to Other ValueOptions’ Consumers
July 1, 2000 through January 31, 2003
State of Arizona
TABLE OF CONTENTS
page xii
Tables (cont’d):
20 Case Management
Consumers in Two RBHAs Arrested Before and After
Participating in HB2003 Case Management Teams
Compared to Other ValueOptions Consumers
July 1, 2000 through January 31, 2003
21 Case Management
Consumers’ Arrest Rate in Two RBHAs Before and After
Participation in HB2003 Case Management Teams Compared
to Other ValueOptions Consumers
July 1, 2000 through January 31, 2003
22 Case Management
Consumers Hospitalized Before and After Participating
in HB2003 Case Management Teams Compared to Other
ValueOptions’ Consumers
July 1, 2000 through January 31, 2003
23 Case Management
Hospitalization Rate Before and After Participating In HB2003
Case Management Teams Compared to Other ValueOptions
Consumers
July 1, 2000 through January 31, 2003
24 Rehabilitation
Consumers Enrolled in Psychosocial and Consumer-Run
Rehabilitation Activities Before and After Participation
in HB2003 Programs
June 1, 2001 through January 31, 2003
a-xxvii
a-xxviii
a-xxix
a-xxx
a-xxxi
continued
Office of the Auditor General
TABLE OF CONTENTS
page xiii
concluded
a-xxxii
a-xxxiii
a-xxxiv
a-xxxv
a-xxxvii
Tables (concl’d)
25 Rehabilitation
Average ALFA-Interpersonal Relations Scores for HB2003
Consumers Enrolled in Psychosocial and Consumer-Run
Rehabilitation Activities
June 1, 2001 through January 31, 2003
26 Rehabilitation
Consumers Enrolled in Educational, Training, and Transitional
Work Programs Before and After Participation in
HB2003 Programs
June 1, 2001 through January 31, 2003
27 Rehabilitation
Consumers Employed Before and After Participation
in HB2003 Programs
June 1, 2001 through January 31, 2003
28 Characteristics of HB2003 Housing Consumers
Compared to ValueOptions’
Waiting List Consumers
29 Characteristics of HB2003 Case Management Consumers
Compared to Other ValueOptions’ Consumers
State of Arizona
page xiv
The Office of the Auditor General has conducted a performance audit examining the
results of appropriating approximately $42 million in special one-time funding for
services to persons with serious mental illnesses. This funding, known as House Bill
2003 (HB2003) funding, was specifically established in Laws 2000, Fifth Special
Session, Chapter 2, §§1 and 5. This legislation also requires the Office of the Auditor
General to examine the success in using the monies to meet agreed-upon perform-ance
standards.1 The program established by the legislation ends on July 1, 2005,
pursuant to Arizona Revised Statutes §36-503.02.
Monies to be used for persons with serious mental illness
Under the approved legislation, the Legislature initially appropriated $50 million from
the State General Fund’s tobacco litigation settlement account to the Department of
Health Services in fiscal 2001. In 2002, the Legislature
reduced the total allocation by $9.5 million. The
Department’s Division of Behavioral Health Services
(Division) reported that it returned the money but added
$1.6 million from accumulated interest earned on the
appropriated funding, resulting in a new total amount of
$42.1 million. According to the legislation, the one-time,
nonreverting funding was to be used for housing, voca-tional
rehabilitation, and other recovery support servic-es
for persons who have a serious mental illness. The
legislation also requires the Department of Health
Services to design services to help these persons
achieve the highest level of self-sufficiency and to
develop performance standards to measure its success
in using the HB2003 monies. Finally, the monies were to be used to supplement and
not supplant existing and future appropriations.
1 Laws 2000, Fifth Special Session, Chapter 2, §5 also appropriated $20 million for funding children’s behavioral health
services. A separate performance audit of the House Bill 2003 children’s services program was released in December
2002 (Report No. 02-12).
Office of the Auditor General
INTRODUCTION
& BACKGROUND
page 1
Serious Mental Illness—Severe, chronic mental illness
(such as schizophrenia) that interferes with a person’s
ability to function in society.
Recovery Support—Services that help consumers gain
control over their mental illness by learning to manage
symptoms, recognize and avert crises, seek help when
needed, and attain their highest level of self-sufficien-cy.
For example, these services include teaching con-sumers
to use a Wellness Recovery Action Plan
(WRAP).
According to the bill’s primary sponsor, the HB2003 monies were intended to allow
the Department to show that additional funding could make a difference in its ability
to serve adults with serious mental illness. Arizona has had long-standing challenges
meeting these needs. In part as a result of a 1981 lawsuit, several reports have exam-ined
Arizona’s behavioral health system and identified needed improvements.1 The
Arnold v. Sarn lawsuit was filed on behalf of people with serious mental illness in
Maricopa County and alleged that the State and Maricopa County failed to provide
them adequate community mental health services as required by law.
One report from 1991—a year when state-wide funding for serious mental illness
totaled $57 million—estimated the total cost of complying with the lawsuit in
Maricopa County for fiscal years 1991 through 1995 at $240 million.2 Funding for
services has increased substantially since the lawsuit, most notably through the addi-tion
of federal Medicaid monies beginning in fiscal year 1990. Still, a 1998 agreement
related to the lawsuit and a 1999 Legislative Task Force report have continued to
identify unmet needs for serving adults with serious mental illness.
HB2003 planning reflects system needs
The HB2003 legislation targets three areas—community housing, vocational rehabil-itation,
and other recovery support services—all of which are areas identified as hav-ing
unmet needs. Recent agreements related to the Arnold lawsuit have focused on
these areas, and the Division’s plans for using the HB2003 monies attempted to
address those needs. For example, a 1998 agreement with the plaintiffs required the
Division to develop strategic plans for housing and vocational and substance abuse
services, and a consultant report required by the agreement identified service needs
in housing, recovery support, and rehabilitation. The Division used the strategic plans
and consultant’s report in identifying HB2003 program service categories and per-formance
measures. Similarly, in 2000, the Division and its Maricopa County
Regional Behavioral Health Authority (RBHA) developed a case management plan
for Maricopa County to replace a plan developed by the Court Monitor. Case man-agement
is a type of recovery support. The Division directed the RBHA to be con-sistent
with this plan in developing its proposal for using HB2003 monies in the
County.
Other reports have also identified needs in those areas and influenced plans for the
HB2003 monies. Specifically, a 1999 service gap analysis for Maricopa County
reported that stakeholders identified three service priorities for persons with serious
mental illness: 1) more aggressive case management, 2) availability of meaningful
1 160 Ariz. 593; 775 P.2d 521; 1989, Maricopa County C-432355.
2 The Blueprint: Implementing Services to the Seriously Mentally Ill, which was the implementation plan intended to ensure
that the court’s judgment would be fully implemented. The Blueprint was issued by the Department of Health Services
and the Maricopa County Board of Supervisors.
State of Arizona
page 2
daily activities, including consumer-run clubhouses, businesses, and social activities,
and 3) additional housing options, including a full continuum of housing that includes
home-based services.1 All three priorities were included in the HB2003 spending
plans. Further, a Legislative Task Force in 1999 noted the need for a state-wide men-tal
health system that provides a continuum of care including housing, rehabilitation,
and vocational services.
A 1999 United States Supreme Court decision and subsequent Presidential
Executive Order also support Arizona’s decision to spend money on improving com-munity-
based mental health services. In Olmstead v. L.C.,2 the court held that unnec-essary
segregation of individuals with disabilities in institutions may constitute dis-crimination
based on disability. In August 2001, three Arizona state agencies—the
Departments of Health Services and Economic Security and the Arizona Health Care
Cost Containment System—completed Arizona’s Olmstead Plan. The plan and its
March 2003 revision described activities that were underway to improve Arizona’s
community-based system, including establishing active community treatment case
1 ValueOptions conducted the gap analysis as part of its service implementation after the Department awarded it the
Regional Behavioral Health Authority (RBHA) contract for Maricopa County in 1998. Stakeholders included officials and
staff of the former RBHA, ComCare, consumers, healthcare providers, state and city agency representatives, and advo-cates.
2 Olmstead v. L.C., 119 S.Ct. 2176 (1999).
Office of the Auditor General
page 3
Arnold v. Sarn lawsuit selected events
1981: A public fiduciary named Arnold files suit on behalf of people with serious mental ill-ness
in Maricopa County, alleging the State did not comply with A.R.S. §36-
550.01(A) which requires it to provide an array of community-based mental health
services to people with serious mental illness.
1986: Maricopa County Superior Court finds on behalf of the plaintiffs.
1995: Exit stipulation sets out terms for fully satisfying the lawsuit, including development
of community living arrangements, appropriate support for people living in the
Arizona State Hospital, and diversion of individuals from the Maricopa County Jail.
1998: Agreement with plaintiffs requires Department of Health Services to create strategic
plans for housing, vocational services, and substance abuse services, and to retain
Human Services Research Institute (HSRI) as a consultant to help determine type,
intensity, and amount of services necessary to meet class members’ needs.
1999: HSRI report identifies needed services, including housing, recovery support, and
rehabilitation.
2000: Case management plan developed for Maricopa County.
management teams, expanding consumer-run services, and using HB2003 monies
for services such as housing and vocational rehabilitation.1
Program monies distributed to RBHAs
The Division allocated approximately $41.6 million of
the $42.1 million in HB2003 funds to the State’s
Regional Behavioral Health Authorities (RBHAs) for
programs and services. The Division contracts with five
RBHAs to provide behavioral health services in their
geographic service areas, and allocated the HB2003
monies to the RBHAs based on service area popula-tion.
Four RBHAs subcontract with behavioral health
service providers in a manner similar to health mainte-nance
organizations, and the fifth, the Excel group in
Yuma, directly provides most services in its region.
Figure 1 shows the five RBHAs, the six geographic
areas they serve, and their HB2003 funding allocations.
Of the $527,000 not transferred to the RBHAs, the
Division paid $227,000 to the Department of Housing
for services provided to RBHAs in acquiring housing
units and, as required by the legislation, transferred
$300,000 to the Office of the Auditor General for this
audit.
Following legislation passage, the Division issued
HB2003 Plan Specifications to the five RBHAs. To
obtain HB2003 monies, each RBHA had to develop a
plan consistent with the specifications. The RBHAs
could propose using the monies to develop housing for
consumers with serious mental illness, and/or to devel-op
recovery support and rehabilitation services to help
consumers achieve their highest level of self-sufficien-cy.
The specifications included an evaluation compo-nent
that listed performance measures for each type of
program (see Table 1, page 5). As required by the leg-islation,
the Office of the Auditor General reviewed
these performance measures, and the Division submit-ted
them to the Joint Legislative Budget Committee for
approval before any of the HB2003 monies were dis-tributed
to the RBHAs.
1 The Division and RBHAs refer to persons receiving services as consumers. For consistency, that term is used in this report
as well.
State of Arizona
page 4
Northern Arizona Regional Behavioral Health Authority (NARBHA)
The EXCEL Group (Excel)
ValueOptions
Pinal Gila Behavioral Health Association (PGBHA)
Community Partnership of Southern Arizona, Region 5 (CPSA-5)
Community Partnership of Southern Arizona, Region 3 (CPSA-3)
Figure 1: Regional Behavioral Health Authorities
Program Fund Allocations
Through June 30, 2005
Source: Department of Behavioral Health Services' letters to Regional
Behavioral Health Authorities (RBHAs) regarding program
funding, May 2002. The allocation covers the entire life of the
program from fiscal year 2001 through fiscal year 2005.
Excel
$1,446,250
NARBHA
$3,939,152
ValueOptions
$24,740,442
PGBHA
$1,629,015
CPSA-5
$8,231,258
CPSA-3
$1,581,136
As of June 30, 2003, the RBHAs reported that they had expended over $34 million
on HB2003 programs (see Table 2, page 6). The Division requires all the monies to
be spent by January 1, 2005. Reported expenditures for HB2003 programs included
the following:
􀁺􇩈 Housing ($13.6 million)—All five RBHAs reported using HB2003 monies to buy
or build housing for consumers with serious mental illness and to provide sup-port
services to help consumers remain in their homes. One RBHA, Excel, chose
to use almost all its HB2003 monies for housing. As a result of this investment,
the RBHAs were able to obtain an additional $5 million from other sources, such
as the United States Department of Housing and Urban Development and the
State Housing Trust Fund. In addition to buying or building new housing, the pro-gram
provided housing assistance monies to 1,304 consumers as of
September 30, 2003. Finding 1 (see pages 13 through 23) provides additional
information about the housing programs.
􀁺􇩃 Case management teams ($12.0 million)—Four RBHAs reported using HB2003
monies to develop intensive case management teams. According to the
RBHAs’ financial reports, the monies paid for consultants to help develop the
teams, train existing staff, create new positions to staff the teams, and provide
Office of the Auditor General
page 5
Table 1: Performance Measures
for Evaluating Outcomes of
HB2003 Programs for Adults with Serious Mental Illness
Type of Program
Performance Measure1 Housing Case Management Rehabilitation
Reduced hospitalization X X
Reduced symptoms X X
Increased housing stability X
Reduced jail and arrests X X
Increased consumer satisfaction X X X
Increased family satisfaction X X X
Increased safety X
Increased social adjustment X X
Reduced substance abuse X
Increased recovery X
Increased vocational functioning X
Increased vocational participation X
1 See Appendix 1, pages a-iii through a-v for more detailed descriptions of specific measures used.
Source: Auditor General staff analysis of HB2003 Evaluation Plan prepared by the Division of Behavioral
Health Services, August 2001, revised February 6, 2003.
State of Arizona
page 6
Table 2: HB2003 Serious Mental Illness (SMI) Program Allocations and Expenditures
From Program Inception through June 30, 2003
(Unaudited)
CPSA-3 CPSA-5 Excel NARBHA PGBHA ValueOptions Total
Total allocation $1,581,136 $8,231,258 $1,446,250 $3,939,152 $1,629,015 $ 24,740,442 $41,567,253
Expenditures
Housing
Development/capital $1,050,000 $1,314,545 $1,315,713 $1,125,366 $ 965,225 $ 4,858,006 $10,628,855
Operations 267,000 1,926,059 2,193,059
Housing assistance 122,489 703,464 825,953
Rehabilitation and recovery
support services
Other services 444 47,040 48,176 2,962,803 3,058,463
Consumer-run services 550,281 841,898 925,617 2,317,796
Clinical teams
Services 904,535 4,239,879 1,177,698 13,187 4,142,889 10,478,188
Site maintenance and operation 210,000 1,109,978 1,319,978
Training 232,036 232,036
Other expenditures
Transportation—capital 30,000 130,536 57,000 26,087 243,623
Telemedicine 327,314 327,314
Extended evaluation 475,365 475,365
Total program expenditures 1,954,979 6,658,745 1,446,249 3,250,138 1,454,302 17,336,217 32,100,630
Administrative expenditures1 87,445 505,852 297,802 137,734 1,139,454 2,168,287
Total expenditures $2,042,4242 $7,164,597 $1,446,249 $3,547,940 $1,592,036 $18,475,671 $34,268,917
1 Excel used all of its HB2003 allocation for program purposes. It did not use any of the monies for administration.
2 CPSA’s total expenditures include additional nonHB2003 monies. CPSA-3 used $487,136 in nonHB2003 monies, and CPSA-5 used an additional $54,618.
Source: Auditor General staff analysis of Division of Behavioral Health Services’ HB2003 allocation and administrative expenditure schedules and the Regional Behavioral Health Authorities’
recaps of HB2003 programs as of June 30, 2003.
consumer services. Finding 2 (see pages 25 through 34) provides additional
information about the case management programs.
􀁺􇩒 Rehabilitation ($5.4 million)—Three RBHAs reported using HB2003 monies to
develop and pay for rehabilitation services, including psychosocial rehabilitation,
education, and vocational programs. Some of the monies paid for developing
consumer-run services such as clubhouses and drop-in centers, and to hire
consumers for peer counseling and “warm lines.” Finding 3 (see pages 35
through 43) provides additional information about the rehabilitation programs.
􀁺􇩏 Other ($1.0 million)—In addition, the RBHAs reported using the HB2003 monies
in other ways. For example, Excel, NARBHA, and PGBHA bought vehicles for
transporting consumers to services and activities. ValueOptions established an
extended evaluation program to assess people requesting seriously mentally ill
eligibility, but whose diagnosis cannot be determined without extensive treat-ment
and stabilization. Finally, PGBHA purchased and installed telemedicine
equipment at service providers’ locations throughout its region. Telemedicine
involves using videoconferencing equipment to increase access to training, psy-chiatric
services, and case staffing meetings between distant sites.
The RBHAs were allowed to use up to 8 percent of the monies for combined admin-istration
and profit, and as shown in Table 2 (see page 6), four RBHAs have used
some of their allocation for administration, totaling approximately $2.2 million as of
June 30, 2003.
More than 3,300 consumers participated in HB2003 pro-grams
Altogether, 3,358 consumers had participated in one or more of the HB2003 pro-grams
by December 31, 2002. Table 3 (see page 8) shows the consumers’ gender,
age, race, ethnicity, and diagnosis as reported in their enrollment and assessment
data. In addition to these 3,358 program participants, ValueOptions had enrolled
another 242 consumers in its extended evaluation program.
The HB2003 program participants represented approximately 13 percent of the near-ly
26,000 adults with serious mental illness who were enrolled in the behavioral health
system as of December 31, 2002. In its plan specifications, the Division directed the
RBHAs to select consumers with four specified types of major mental illness to par-ticipate
in the HB2003 programs: schizophrenia, delusional disorders, affective psy-choses
such as bipolar disorder, and other psychoses. According to the Division’s
former medical director, sufficient research exists on these illnesses to make them
more predictable than serious mental illness in general. Some RBHAs added further
Office of the Auditor General
page 7
State of Arizona
page 8
Table 3: Number of HB2003 Consumers with a Serious Mental Illness Served
As of December 31, 2002
CPSA-3
CPSA-5
Excel
NARBHA
PGBHA
ValueOptions
Total
Percentage
Total number
44
188
63
128
111
2,824
3,358
100.0
Demographic categories
Gender
Female 14 88 34 69 63 1,475 1,743 51.9
Male 30 100 29 59 48 1,349 1,615 48.1
Age Groups
18-25 5 28 9 4 166 212 6.3
26-35 5 33 14 10 22 485 569 17.0
36-45 13 57 14 38 34 890 1,046 31.1
46-55 15 53 20 51 31 801 971 29.0
56-65 5 14 6 23 16 347 411 12.2
66 and over 1 3 6 4 135 149 4.4
Race
White 44 167 44 114 100 2,001 2,470 73.5
Black/African-American 12 4 4 9 564 593 17.7
Asian 1 2 93 96 2.9
Native-American 5 5 1 32 43 1.3
Other/unknown 4 9 9 134 156 4.6
Ethnicity
Hispanic1 4 14 14 10 15 373 430 12.8
Non-Hispanic 40 174 49 118 96 2,451 2,928 87.2
Diagnosed with a serious mental illness
Delusional disorder 2 3 9 14 0.4
Major depressive disorder 18 92 30 64 51 1,091 1,346 40.1
Schizophrenia 19 70 28 44 40 1,126 1,327 39.5
Other psychotic disorder 3 10 1 7 9 199 229 6.8
Other/unknown 2 13 4 13 11 399 442 13.2
CPSA-3—Community Partnership of Southern Arizona—Cochise, Graham, Greenlee, and Santa Cruz Counties
CPSA-5—Community Partnership of Southern Arizona—Pima County
NARBHA—Northern Arizona Regional Behavioral Health Authority
PGBHA—Pinal Gila Behavioral Health Association
1 A Hispanic individual can be any race.
Source: Auditor General staff analysis of enrollment and assessment data provided by the Division of Behavioral Health Services and its Regional Behavioral Health Authorities, including all
consumers enrolled from program inception through December 31, 2002.
selection criteria in their proposals for using the HB2003 money. For example,
NARBHA planned to focus on individuals identified as high utilizers of their services,
ValueOptions targeted its plan to the Arnold v. Sarn priority population, and PGBHA
planned to target its case management to consumers with the greatest need.
The impact of HB2003 will extend beyond this group of participating consumers. For
example, the housing purchased using HB2003 monies will continue to be used for
persons with serious mental illness for at least 15 years under use restrictions on the
properties. In addition, the RBHAs plan to continue other programs that were sup-ported
with HB2003 monies, such as the consumer-run drop-in centers and club-houses.
According to division officials, they plan to conduct an evaluation of the programs
that the RBHAs developed with their HB2003 monies once the RBHAs have spent all
the monies. Similar to this audit, the Division plans to assess the RBHAs’ programs
in accordance with the performance measures that the Joint Legislative Budget
Committee (JLBC) approved.
Scope and methodology
As required by legislation, this audit report focused on the Division’s ability to meet
the performance measures it established for its three major programs (see Table 1,
page 5, and Appendix 1, page a-iii through a-v), and contains findings in all three
areas:
􀁺􇩆 First, consumers benefited from the housing programs, but the Division should
conduct its own impact analysis since consumers at only three RBHAs had lived
in the housing long enough to be included in the audit analysis.
􀁺􇩓 Second, consumers benefited from the intensive case management programs,
but the Division should conduct its own analysis on arrests since only two of four
RBHAs had complete enough information to include in the Auditor General’s
analysis, and also look at length of hospital stay. In addition, it should determine
the causes for the lack of results at one RBHA.
􀁺􇩔 Third, consumers increased their participation in rehabilitation activities, particu-larly
at two RBHAs, but the Division should conduct its own analysis to deter-mine
whether other consumers eventually increase activity levels.
A combination of the following methods was used in the audit:
􀁺􇩁 Auditors conducted two main types of analysis to examine the outcomes of the
HB2003 programs. To conduct both parts of the outcome analysis, auditors
Office of the Auditor General
page 9
obtained and verified records from the Division’s enrollment, assessment, and
encounter (services provided) databases for the period July 1, 2000 through
December 31, 2002 (enrollment data), or January 31, 2003 (assessment and
encounters). The first type of analysis compared consumer symptoms and func-tioning
levels, housing independence status, participation in vocational and
rehabilitation activities, arrests, and hospitalizations before and after program
participation. The second type of analysis compared program participants’
symptoms and other performance measures with those of similar consumers
who did not participate in the programs.
Appendix 2 (see page a-ix) provides detailed results of the outcome analysis.
􀁺􇩔 To understand the results of the outcome analysis and put them in context, audi-tors
reviewed division program specifications, RBHA spending plans, pertinent
literature regarding each program (see Bibliography, pages a-xli through a-xvii),
criteria that the Division established for each program, and RBHA reports show-ing
whether their programs matched the Division’s criteria. Auditors also exam-ined
documents related to the Arnold lawsuit regarding persons with serious
mental illness and interviewed representatives of the plaintiffs’ attorneys and the
court monitor’s office.
􀁺􇩔 To assess the housing programs that received HB2003 monies, auditors toured
16 housing sites, interviewed RBHA and service provider staff, and interviewed
14 consumers living at the sites. To determine whether the Division used sound
procedures for selecting housing and ensuring its continued use for persons
with serious mental illness, auditors interviewed Arizona Department of Housing
officials and examined documents showing their review and approval of division
proposals, reviewed purchase documents showing the terms and conditions for
use of purchased or constructed housing, reviewed consumer leases, and
reviewed division expenditure reports and documents showing how the RBHAs
and service providers used HB2003 monies as matching funds to obtain hous-ing
money from other sources.
􀁺􇩔 To assess the case management programs that received HB2003 monies, audi-tors
met with 19 members of the new case management teams, interviewed 8
consumers, surveyed 10 service providers, examined training plans and related
materials, and reviewed a letter and other documents illustrating individual con-sumers’
experiences with the case management teams. Auditors also examined
reports of successful intensive case management programs in other areas of
the country, including the Madison, Wisconsin, Program of Assertive Community
Treatment, which first developed and tested the principles of intensive case
management.
􀁺􇩔 To assess the rehabilitation programs that received HB2003 monies, auditors
toured two consumer-run programs, including one consumer recovery support
State of Arizona
page 10
center in Prescott and one clubhouse in Pima County; and conducted site visits
at two ValueOptions HB2003 clinical sites and three non-HB2003 ValueOptions
clinics. Auditors also interviewed four NARBHA, two CPSA, and ten
ValueOptions consumers; interviewed nine ValueOptions’ rehabilitation special-ists;
reviewed a videorecording of consumer and staff speeches at a peer sup-port
training graduation ceremony; and reviewed a consultant’s report regard-ing
rehabilitation services in Southern Arizona. In addition, auditors interviewed
officials and six vocational counselors at the Department of Economic Security
Rehabilitation Services Administration (RSA) and examined the Interagency
Service Agreement between RSA and the Division of Behavioral Health Services
that explains each agency’s responsibilities.
This audit was conducted in accordance with government auditing standards.
The Auditor General and staff express appreciation to the director of the Department
of Health Services, and management and staff of the Division of Behavioral Health
Services and its Regional Behavioral Health Authorities for their cooperation and
assistance throughout the audit.
Office of the Auditor General
page 11
State of Arizona
page 12
Consumers benefited from housing programs
According to their quarterly reports to the Division, the RBHAs used $13.6 million in
HB2003 monies, or approximately 40 percent of the total spent as of June 30, 2003,
to develop housing and related programs. RBHAs developed 334 new housing
spaces, which was an increase of about one-fourth over the roughly 1,250 spaces
previously available. The impact of the housing program varied by RBHA and by con-sumers’
level of functioning. In general, consumers with more severe levels of dys-function
showed the greatest improvement from living in the new housing.
Consumers with slight levels of dysfunction showed little or no change. However,
since two RBHAs’ new-housing consumers had not lived in their homes long enough
to be included in this audit’s analysis, the Division should conduct its own analysis of
the housing program’s impact and provide technical assistance to the RBHAs based
on the results of its research.
Housing important for consumers with serious mental
illness
According to research, stable housing is an important factor in a consumer’s recov-ery
from mental illness. Consumers without stable housing focus on meeting their
basic needs, and cannot focus sufficiently on their recovery. However, people with a
serious mental illness commonly cannot attain suitable housing, and even lose their
homes and become homeless. For example, issues such as criminal records and
substance abuse can disqualify people as renters or borrowers, and increase their
likelihood of becoming homeless. According to a housing plan written by two state
agencies, Arizona also has a shortage of affordable housing for lower-income peo-ple,
which includes many individuals with serious mental illness. This plan suggests
that 17,000 low-income Arizonans with severe and persistent mental illness are at risk
of becoming homeless.1 Additionally, the Division estimates that there are at least
Stable housing is an
important factor in
recovery from mental ill-ness.
1 Department of Commerce, Department of Economic Security, FY 2000-2004 State of Arizona Consolidated Plan.
Office of the Auditor General
FINDING 1
page 13
1,500 individuals with a serious mental illness who are homeless in Maricopa County,
and another 750 individuals who lack adequate and/or safe housing.
Research shows that people with a serious mental illness need housing that is coor-dinated
with other support services. For example, one national expert reports that
people with a serious mental illness need access to an array of residential options
offering varying levels of supervision, coordinated with other recovery support serv-ices,
to achieve the highest level of self-sufficiency. A recent study at the University of
Arizona compared outcomes for persons in housing that provides daily on-site treat-ment
services with persons in independent housing. The study looked at various out-comes
including hospitalization, use of emergency rooms or crisis services, and time
served in jail, and found that residents in both types of housing fared about the same.
However, those in the independent housing had longer stays in their original place-ment
and were less likely to experience an episode of homelessness.
Further, consumers should have some say in the decision to live in either supervised
or independent housing. In one study, consumers who were given a choice among
housing options reported greater housing satisfaction, improved housing stability,
and greater psychological well-being. Another study found that lack of consumer
choice can actually accelerate homelessness because consumers may choose the
relative independence of the streets to the restrictions of a highly structured residen-tial
facility. One theory to explain this phenomenon is that choice provides opportuni-ties
for people with serious mental illness to experience a sense of control over life
events.
Decisions in two lawsuits confirm the State’s responsibility for providing community
housing to persons with serious mental illness. First, the 1996 Maricopa County
Superior Court-approved exit agreement for the Arnold v. Sarn lawsuit requires the
Division to provide an array of flexible community housing options for people with
serious mental illness, and the 1998 supplemental agreement required the Division
State of Arizona
page 14
Case Example
J.O. has been in the mental health system for more than 20 years and had been separated
from her family for years. During the past year, J.O. had various psychiatric relapses. Her
symptoms included delusions and hallucinations, including a fear that she was being poi-soned,
resulting in her discontinuing her medications. The clinical team worked on trying
to build enough trust to allow for referral to multiple programs that could help her. J.O. was
placed in HB2003 housing, and received home and self-management skills training. She
stabilized on her medications, participated in activities outside her home, and performed
her daily activities with greater skill. She had not experienced a psychiatric relapse in 8
months as of August 2003. She left her HB2003 housing only because her physical health
has deteriorated and required a higher level of nursing care.
to develop a housing strategic plan.1 Similarly, the 1999 U.S. Supreme Court deci-sion
in Olmstead v. L.C. prohibits keeping disabled persons in institutions unneces-sarily
and requires states to provide community-based placements to persons who
might otherwise be institutionalized.2
Housing and housing support
provided
To support the goals of HB2003, the RBHAs
reported that they spent more than $13.6 million
developing a number of housing programs to
increase participants’ self-sufficiency either by
providing more independent housing or helping
them maintain existing housing.
HB2003 monies used to acquire variety
of housing—The RBHAs and their subcon-tracted
service providers reported using approxi-mately
$10.6 million of the HB2003 monies to buy
or build houses and apartments at 39 sites in 21
cities around the State. The new housing pro-vides
334 additional beds, an increase of about
one-fourth over the Division’s approximately
1,250 previously available beds as reported by
the Division and its RBHAs.3 Figure 2 shows the
general locations of the new housing, and
Appendix 3 (see page a-xli through a-xliii) pro-vides
detailed information about the locations,
types, costs, opening dates, and housing occu-pancy.
Altogether, the RBHAs had placed 272 HB2003
consumers in the new housing by September 30,
2003 (see Table 4, page 16). In addition, 96 other
tenants were placed in HB2003 housing, includ-ing
children of the HB2003 consumers and other
persons with serious mental illness not designat-ed
as HB2003 participants. The first tenant
1 160 Ariz. 593; 775 P.2d 521; 1989, Maricopa County C-432355.
2 Olmstead v. L.C., 119 S. Ct. 2176 (June 22, 1999).
3 The number of beds previously available is an approximation because persons with serious mental illness may qualify
for other low-income housing such as U.S. Department of Housing and Urban Development (HUD) program housing. In
addition, some available beds are occupied by family members of persons with serious mental illness.
Office of the Auditor General
page 15
Northern Arizona Regional Behavioral Health Authority (NARBHA)
The EXCEL Group (Excel)
ValueOptions
Pinal Gila Behavioral Health Association (PGBHA)
Community Partnership of Southern Arizona, Region 5 (CPSA-5)
Community Partnership of Southern Arizona, Region 3 (CPSA-3)
Excel
NARBHA
ValueOptions
PGBHA
CPSA-5
CPSA-3
Figure 2: House Bill 2003 Housing Locations by Regional
Behavioral Health Authorities
As of June 30, 2003
Source: Auditor General staff analysis of data provided by the Arizona Department
of Housing and the Regional Behavioral Health Authorities.
moved into an Excel apartment complex in
Yuma on February 5, 2001, but most projects
did not open until 2002 or 2003. (See Appendix
3, pages a-xli through a-xliii.)
Generally, the new housing falls into two broad
categories:
􀁺􇩓 Supervised Housing (93 beds)—Two
RBHAs—NARBHA and ValueOptions—devel-oped
supervised housing, which is designed to
be individualized and integrated into the com-munity,
in the most typical and least-restrictive
setting possible. The consumer’s supervisory
needs can range from individuals who can man-age
noncrisis issues for 1 or 2 days until a
scheduled staff visit, to individuals who require
substantial support and skill training in a struc-tured
environment. These 15 new houses and
apartments can house a maximum of 93 indi-viduals.
􀁺􇩉 Independent Living (241 beds)—All five RBHAs developed independent liv-ing
options, which include both apartments and single-family houses. These
are settings where an individual can live without on-site supervision from
mental health staff. The 24 new HB2003 sites can house a maximum of 241
individuals.
Since self-sufficiency is the HB2003 program’s goal, consumers must pay rent to
live in the new housing. Generally, monthly rent is 30 percent of the consumer’s
monthly income. This amount matches federal guidelines for affordable low-income
housing. These monies are used to maintain the housing. Consumers in
some independent living sites can bring their families to live with them, just as
they would if they were renting on their own. In addition, consumers sign a lease
and must abide by its terms and restrictions. Consumers can remain in the hous-ing
as long as they choose, unless they violate the terms of the lease. Tenure in
housing is an important aspect of housing stability.
Other programs support consumers in community housing—
Two RBHAs—ValueOptions and PGBHA—used part of their HB2003 monies for
other housing-related services. They had served 1,304 consumers through these
other housing-related programs by September 30, 2003 (see Table 4).
ValueOptions allotted approximately $3.8 million for an in-home housing assis-tance
program that provides training and assistance in daily living skills such as
meal preparation, housekeeping, budgeting, and social and recreational activi-
State of Arizona
page 16
Table 4: Number of HB2003 Housing Consumers by RBHA
February 1, 2001 through September 30, 2003
Number of
Consumers in
HB2003
Housing
Number of
Consumers
Receiving Housing
Assistance Monies1
Total
Number of
Housing
Consumers
CPSA-5 35 35
Excel 77 77
NARBHA 11 11
PGBHA 22 115 137
ValueOptions 127 1,189 1,316
Total 272 1,304 1,576
1 Column includes housing assistance, move-in assistance, and community tenure support
programs.
Source: Auditor General staff analysis of RBHA program enrollment rosters for the period
February 1, 2001 through September 30, 2003.
ValueOptions house providing 24-hour supervised living.
Excel apartment complex providing independent living.
ties to most of its HB2003 housing participants. In addition, ValueOptions and
PGBHA set aside some funding to help consumers remain in existing community
housing or make the transition from homelessness to housing. Specifically,
ValueOptions allotted $500,000 for a move-in assistance program to help consumers
pay expenses such as security and utility deposits. ValueOptions also allocated
$210,000 for a community tenure program that helps consumers keep their homes
by paying rent or utilities if they get behind in their payments. Both programs have a
dollar limit from $1,000-$1,500 per consumer and are one-time-only. PGBHA spent
about $122,500 on its housing assistance program.
Consumers benefit from housing programs
Consumers at ValueOptions and Excel benefited from the HB2003 housing.1 These
consumers showed greater improvements in a variety of performance measures
than did two comparison groups. (See Appendix 2, page a-ix through a-xiv, for more
details on the comparison groups.) When controlling for functioning level, Value
Options showed effects for all functioning levels, while Excel showed effects for more
moderately functioning consumers. Excel’s higher-functioning consumers showed
deterioration in their functioning levels. However, consumers in both RBHAs general-ly
either maintained or increased their level of independence.
Continued analysis of the HB2003 housing’s impact is needed. Auditors’ analysis
was performed with limited data from ValueOptions, Excel, and CPSA-5 consumers.2
Consumers in the other two RBHAs generally had not moved into the new housing
early enough to be included in this analysis. Further, some outcomes, such as hos-pitalizations
and arrests, occurred so rarely among consumers that auditors were
prevented from drawing meaningful conclusions.
Consumers’ functioning improved in new housing—Consumers who
lived in the new housing for at least 6 months made greater gains on a variety of per-formance
measures than consumers on a waiting list for the new housing. Several
performance measures were identified for evaluating the outcomes of the housing
program, and HB2003 consumers showed more improvement than their counter-parts
in two comparison groups on most measures, as shown in Table 5 (see page
18). Gains for consumers in the new housing occurred on all six examined dimen-sions
of the Arizona Level of Functioning Assessment (ALFA), with the strongest and
most consistent gains in the family and living environment dimension, as shown in
Table 8 (see Appendix 2, page a-xv).
As shown in Table 9 (see Appendix 2, page a-xvi), when results are analyzed by
RBHA, only ValueOptions consumers had statistically significant gains in most meas-
1 The evaluation time frame spanned approximately 24 months, from the first time a consumer moved into HB2003 hous-ing
in February 2001 through January 31, 2003.
2 The number of consumers at CPSA-5 was too small to make meaningful comparisons across RBHAs. However, the
CPSA-5 consumers are included in state-wide results.
Office of the Auditor General
page 17
State of Arizona
page 18
Table 5: Housing
Progress of HB2003 Housing Consumers
and Two Comparison Groups
by Performance Measure1
July 1, 2000 through January 31, 2003
Consumers in HB2003
Housing Compared To
ValueOptions
Consumers ValueOptions
Performance Measure in Non-HB2003 Homeless
and Expected Outcome Housing Consumers
Arizona Level of Functioning Assessment (ALFA)
Family, living environment (increased safety) 􀁺􇨠 􀁺􇨠
Feeling, affect, mood (reduced symptoms) 􀁼􇰠 􀂀􈀠
Interpersonal relations (increased social adjustment) 􀂀􈀠 􀁼􇰠
Self-care (increased self-sufficiency)2 􀂀􈀠 􀂀􈀠
Substance abuse (reduced substance abuse) 􀂀􈀠 􀁼􇰠
Thinking and cognition (reduced symptoms) 􀁼􇰠 􀂀􈀠
Clinical Global Impression (CGI)
Global improvement (reduced symptoms)2 􀁼􇰠 􀁼􇰠
Severity of symptoms (reduced symptoms)2 􀁼􇰠 􀁼􇰠
Housing independence (increased self-sufficiency)2 NA NA
Hospitalization (reduced hospitalizations)
Rate of admissions NA NA
Length of stay NA NA
Arrests (reduced arrests) NA NA
Symbol key:1
􀁺􇨠 Improved much more than comparison group
􀂀􈀠 Improved more than comparison group
􀁼􇰠 No difference between groups
􀂵􋔠 Worsened more than comparison group
NA not available
1 See Appendix 2, Tables 10 and 11 (pages a-xvii and a-xviii), for detailed results on each measure.
Differences greater than 10 percent of the total available points on the measure (5 out of 50 for
ALFA; 0.7 out of 7 for CGI) are shown as improved much more than comparison groups.
Differences that were not statistically significant are shown as no difference between groups.
2 Not a performance measure identified by the Division and the RBHAs for housing.
Source: Auditor General staff analysis of assessment data provided by BHS and the RBHAs for the
period of July 1, 2000 through January 31, 2003.
ures of symptom severity. At Excel, consumers made gains only on the substance
abuse dimension of the ALFA. Both ValueOptions and Excel included substance
abuse prohibitions in the lease requirements for the new housing, which may help to
explain the improvement on that measure at both RBHAs.
At ValueOptions, consumers with the most severe dysfunction before being placed
in their housing showed the most dramatic gains, as shown in Table 9 (see Appendix
2, page a-xvi). On average, these consumers gained enough to move them to the
moderate dysfunction range. Consumers in the comparison groups who started with
the severest dysfunction also made gains (see Table 10, Appendix 2, page a-xvii),
suggesting there may be a natural tendency for the most severe consumers to show
improvement, but their gains were smaller than those for the consumers in the
HB2003 housing. Consumers in the moderate functioning range at ValueOptions
also made modest gains, and those consumers with slight dysfunction stayed sta-ble.
At Excel, consumers in the more moderate ranges made significant gains while those
classified as having only slight dysfunction remained relatively stable. There was no
statistically significant change for the most severely impaired consumers at Excel, but
the number of consumers in this category was relatively small.
Another scale measuring symptom severity, the Clinical Global Impression (CGI),
showed mixed results for HB2003 consumers. The CGI measures the effects of psy-chotropic
medications, and is completed by the clinician who monitors consumer
medications. It includes assessments of symptom severity and improvement in their
condition, and is a commonly used measure of global functioning. The differences
between HB2003 consumers and the waiting list group consumers were not statisti-cally
significant, suggesting that there is no difference between HB2003 consumers
and the comparison group consumers on these two scores when all three RBHAs’
consumers are combined. However, ValueOptions’ consumers improved on severity
and stayed the same on improvement, while Excel’s consumers stayed the same on
severity and got worse on improvement. Results for the CGI are shown in Tables 11
and 12 (see Appendix 2, pages a-xviii and a-xix).
Consumers in new housing are independent—The final measure exam-ined
for consumers in both RBHAs’ new housing showed that their level of inde-pendence
remained the same or improved after entering the HB2003 program.
About one-third of the consumers moved into more independent housing, and about
two-thirds remained at the same level of independence. Most of the consumers at
Excel started and stayed at a very high level of independence. At ValueOptions, most
consumers started at a lower level of independence and moved to a higher level,
while those who started at the highest level of independence remained at that level.
Consumers satisfied with new housing—Auditors interviewed 14 consumers
living in the new housing. Most reported satisfaction with their new housing situation,
Office of the Auditor General
page 19
although two said they would prefer to live in other situations. For example, a
ValueOptions consumer who lives in a four-bedroom house with three other men said
he would like to be on his own, although he likes living in the house. However, a court
order required him to move into a supervised setting when he left the Arizona State
Hospital. One consumer told auditors he is very happy in his Excel apartment, where
he has more responsibility and more freedom than he had in previous placements.
He said he is learning living skills and has friends at the apartment complex, and
wants to stay there. Another consumer at the same complex said he had been home-less
for many years, and had felt a lot of stress in previous residential placements,
but now he is comfortable and gets a good night’s sleep. A consumer in a transitional
facility in Yuma told auditors she had been living in her van for about 2 years, and she
feels much better and suffers less from panic, anxiety, and depression.
Differences in consumers and programs may help to explain differ-ent
results—Excel and ValueOptions served different consumers and accordingly
designed their new housing programs differently, with Excel providing more inde-pendent
living and ValueOptions providing more 24-hour supervised settings, as
shown in Appendix 3 (see pages a-xxxix through a-xliii). The differences in programs
and consumers may help characterize Excel’s gains in comparison to ValueOptions’,
even though, on average, the Excel consumer had lived in the new housing longer.
In general, consumers with the most severe dysfunction made the greatest gains, but
Excel’s consumers are not proportionately as severe in dysfunction as ValueOptions’.
Therefore, they may have been less likely to make large gains. Most of Excel’s con-sumers
were in the slight-to-moderate dysfunction range prior to move-in, while most
ValueOptions’ consumers were in the moderate or severe range. As shown in Table
9 (see Appendix 2, page a-xvi), Excel’s gains are limited to the moderately function-ing
group.
In addition, most of Excel’s consumers live in housing that affords them greater inde-pendence
than ValueOptions’ consumers, and while still integrated with services,
offers fewer in-home services. Most ValueOptions consumers received services from
an in-home program that trains and assists consumers in daily living activities.
Further, most ValueOptions’ sites are supervised housing. Excel by contrast relied
more on independent housing, offering the same services to HB2003 consumers as
to other consumers, though with more focus on in-home assistance. Although a
recent University of Arizona study found independent housing yields similar gains to
housing with more supervision, and Excel and ValueOptions were comparable for
those consumers with moderate dysfunction, Excel’s consumers with slight dys-function
showed a deterioration in the interpersonal relations dimension of the ALFA
(see Table 9, page a-xvi).
Continued analysis important—Consumers in three RBHAs—CPSA, NARBHA,
and PGBHA—generally had not moved into HB2003 housing early enough to be
included in this audit’s analysis. In addition, hospitalizations and arrests are rare
State of Arizona
page 20
Consumers report satis-faction
with their new
housing.
among the consumers in the new housing, so auditors had insufficient data to draw
conclusions about those two performance measures. The Division should conduct
additional analysis to follow up on the results of the Auditor General’s analysis and
draw additional conclusions about the impact of HB2003 housing programs and
services. Specifically, because auditors found differences in the impact of the new
housing between the RBHAs included in this analysis, the Division should analyze
performance indicator data regarding the other three RBHAs when their consumers
have lived in the new housing at least 6 months. In addition, the Division should ana-lyze
the program’s impact on hospitalization and arrests for consumers at all the
RBHAs that invested in housing once sufficient data is available. Finally, the Division
should work with Excel to determine what outcomes should be expected for con-sumers
in Excel’s independent housing and analyze the impact of Excel’s program
against those expected outcomes. The Division could conduct these analyses as
part of the evaluation it plans to conduct once the RBHAs have spent all their HB2003
monies. Based on analysis results, the Division should develop any needed recom-mendations
and provide technical assistance to improve the RBHAs’ housing pro-grams
for persons with serious mental illness.
Programs appear well-designed and help address hous-ing
gap
Although the programs’ impacts on consumer functioning and symptom severity
were modest, the planning and oversight mechanisms that the Division put in place
prior to approving the RBHAs’ various HB2003 housing projects appear to be appro-priate.
For example, the Division worked with the RBHAs to establish housing pro-gram
guidelines based on a national housing model for persons with serious mental
illness and reviewed the RBHA projects according to these standards. The Division
also involved the Arizona Department of Housing (Housing) in its decisions regard-ing
property acquisition because of its experience in developing public housing. The
projects have also helped the Division address legal requirements set forth in the
Arnold v. Sarn litigation and meet goals that it set forth in the court-approved housing
strategic plan.
Division monitors programs’ adherence to standards—The Division and
the RBHAs developed housing program measures based on a national model for
housing programs. Every 6 months, each RBHA must assess each housing project
according to the measures and report to the Division on each site’s fidelity to the
model. The report scores each program on five areas: choice of living arrangements,
separation of housing and service staff, residents’ rights of tenancy consistent with
landlord/tenant law, residents’ choice of accepting behavioral health services, and
social/recreational activities. According to division officials, all the open housing sites
inspected through July 17, 2003, currently meet these standards.
The Division involved
the Arizona Department
of Housing in its deci-sions
regarding property
acquisition.
Office of the Auditor General
page 21
Department of Housing helps acquire and protect assets—Prior to
using any HB2003 monies to acquire housing, the Division entered into an intera-gency
agreement with the Arizona Department of Housing for technical assistance.
The Division paid Housing $228,000 for its services. Specifically, Housing helped
each RBHA identify its goals and obtain HB2003 properties. Housing provided an
application package, which the RBHA and/or service provider filled out prior to mak-ing
any purchase. Housing staff reviewed the application and toured each prospec-tive
site, considering issues such as location, price, and condition of the structure
prior to approving the application. After housing officials approved the application,
they forwarded it to the Division for review. The Division considered other issues, such
as sustainability, before approving the application and releasing monies for the pur-chase.
In addition to assisting with the purchasing process, Housing also helped some
RBHAs use their HB2003 funds as a match to obtain monies from other sources,
such as the United States Department of Housing and Urban Development’s
Supportive Housing Programs, and the State Housing Trust Fund. Altogether, the
RBHAs obtained an additional $5 million from these sources and were able to pur-chase
more housing for individuals with serious mental illness.
Finally, to protect the State’s investment, Housing worked with the Attorney General’s
Office to develop use restrictions specifically for the HB2003 housing. These 15-year
use restrictions require the projects to be used exclusively for housing adults with
serious mental illness. If the RBHA or its subcontractor does not conform to the
restrictions, the State can take possession of the property by declaring the agency in
default of the contract. While the restrictions are in place, Housing will inspect the
housing sites annually. After 15 years, the State lifts the restrictions, and the RBHAs
or service provider agencies will own the properties outright.
The Division and its RBHAs should continue to work with Housing to find funding for
additional housing projects in Maricopa County and the rest of the State, as long as
the Division’s analysis results indicate the programs are having an impact. Those
funds could then be matched to other federal or state funds, similar to the methods
used on several HB2003 housing projects.
Housing helps address Arnold v. Sarn agreement—Finally, the housing
also helped the State address the terms of the Arnold v. Sarn exit agreement and the
housing strategic plan required by the agreement. For example, the agreement
required the Department to provide 300 community living arrangements for individu-als
living in supervisory care homes and/or board and care homes. Most of
ValueOptions’ 109 beds were targeted to serve the priority populations identified in
this exit agreement, such as those identified above. Likewise, the housing strategic
plan proposed developing a plan to fill housing gaps for people with serious mental
illness. The Division and ValueOptions report using HB2003 funding to partially fill the
identified housing gaps. However, despite the addition of HB2003 housing, the
RBHAs used HB2003
monies to obtain addi-tional
financial support.
State of Arizona
page 22
The average cost of each
new bed in the program is
$3,314 per year for 15
years.
Division estimates that more than 2,000 people in Maricopa County, as well as peo-ple
in other urban and rural regions, still need housing.
Recommendations
1. The Division should conduct its own impact analysis of HB2003 housing pro-grams
and services. Specifically, the Division should:
a. Assess consumers’ progress at CPSA, NARBHA, and PGBHA after their
consumers have lived in the new housing for at least 6 months.
b. Determine the HB2003 housing programs’ impact on hospitalization and
arrests once sufficient data becomes available.
c. Work with Excel to determine what outcomes should be expected for con-sumers
in Excel’s independent housing, and analyze the impact of Excel’s
housing program against those expected outcomes.
The Division could conduct the analyses identified above as part of the HB2003
program evaluation it plans to conduct once the RBHAs have expended all of
their HB2003 monies.
2. The Division should develop recommendations and provide technical assis-tance
to the RBHAs to improve consumer housing based on the results of its
research.
Office of the Auditor General
page 23
State of Arizona
page 24
Consumers show modest gain from
intensive case management programs
The RBHAs used $12 million of HB2003 monies, or 35 percent of total spending as
of June 30, 2003, to develop intensive case management teams. These teams pro-vide
a range of case management and other services, often at the consumer’s home
or in other community settings. HB2003 consumers made modest improvements in
symptoms, while a comparison group stayed the same or worsened. Further, among
those consumers with the most severe symptoms, greater gains are apparent. Only
one RBHA, PGBHA, did not show expected gains. The RBHAs plan to carry the pro-grams
forward using different funding and create new programs based on the
HB2003 model. These plans to continue the case management model developed
with HB2003 monies increase the importance of the Division’s and RBHAs’ follow-up
evaluations.
Intensive case management teams developed
To support HB2003 goals of supporting recovery and helping people with serious
mental illness achieve the highest level of self-sufficiency, four RBHAs established
new intensive case management teams.1 Intensive case management teams pro-vide
a range of services, including substance abuse and vocational counseling,
medication management, and life-skills training. These teams differ from traditional
case management in their staffing structure, caseload size, and frequency of contact.
In addition, team members provide many services directly instead of coordinating all
services through other providers, as in traditional case management. Several
research studies on Assertive Community Treatment (ACT), a form of intensive case
management, have linked this approach with decreased symptom severity, fewer
hospitalizations, and increased life satisfaction. The RBHAs report using $12 million
in HB2003 monies to pay for training and consultation to establish the teams, team
member and other staff positions, and services provided by the teams.
Four RBHAs established
new intensive case
management teams.
1 CPSA, NARBHA, PGBHA, and ValueOptions established these teams. CPSA developed teams in both its geographic
service areas. The fifth RBHA, Excel, reports that it used all its HB2003 monies for its housing program and transporta-tion.
Office of the Auditor General
FINDING 2
page 25
The RBHAs developed two main types of teams:
􀁺􇩈 High-intensity case management teams—All four RBHAs developed teams that
deliver high-intensity case management, often in community settings such as
the consumer’s neighborhood or at an employment site. The RBHAs and their
providers established a variety of teams that incorporate some, though not all,
features of the ACT model. Each RBHA uses teams of behavioral healthcare
professionals and technicians such as housing, rehabilitation, or vocational,
substance abuse, and living skills specialists to provide highly individualized,
direct services. For example, Superstition Mountain Mental Health Center, a
PGBHA provider, has a high-intensity case management team that includes a
living skills specialist who teaches cooking and nutrition classes and other skills
that allow consumers with disabilities to live more independently. At one CPSA
provider, the high-intensity case management team includes a registered nurse
with substance abuse treatment experience. Team services are available to
some providers’ consumers 7 days a week, 24 hours a day, while other
providers rely on their existing crisis system for after-hours services. Low case-loads—
as few as 60 consumers per case management team at ValueOptions
and PGBHA, or 12 consumers per staff member—enable the teams to provide
this intensive level of service. In contrast, service providers stated that normal
caseloads can range from 35 to 100 consumers per staff member. According to
the Division, staffing levels and the degree of community-based services vary
according to each RBHA’s resources and geography.
􀁺􇩓 Supportive treatment teams—ValueOptions developed this less-intensive pro-gram
for consumers who have achieved higher levels of functioning and require
less-intensive levels of case management. Supportive treatment teams focus on
maximizing community resources and coordinating care for the consumer.
Providers and state agencies are much more involved in the care of these con-sumers,
and a lesser emphasis is placed on direct services from the team. Still,
consumers receive services such as substance abuse and vocational counsel-ing,
consumer advocacy, and individual therapy through these teams. Because
services are less intensive than high-intensity case management, staff-to-con-
Supportive treatment
teams have served the
highest number of
HB2003 consumers.
State of Arizona
page 26
Case Example
B.W., a 42-year-old ValueOptions consumer, had been in the care of his parents his entire
adult life and required a great deal of support to get through a typical day. Since 1990, he
was in and out of the behavioral health system four times. He almost constantly heard voic-es,
and he was delusional and irritable. He experienced difficulty attending to personal
hygiene and was virtually unable to live independently. However, after a year of high-inten-sity
case management, B.W. has been free from symptoms for several months, voluntarily
takes his medication, lives semi-independently, and would like to return to work.
sumer ratios are targeted at 1:30. Supportive treatment teams account for 77
percent of all consumers enrolled in HB2003 programs. According to
ValueOptions financial reports dated June 30, 2003, ValueOptions had expend-ed
approximately $1.3 million for supportive treatment teams as of June 30,
2003, compared to $3.2 million for its high-intensity case management teams.
As shown in Table 6, 2,221 consumers, or about 8.5 percent of the adults with seri-ous
mental illness in the behavioral health system, had participated in these pro-grams
as of December 31, 2002. However, not all
had participated in the programs for at least 6
months and had complete assessment data,
so only 1,548 (70 percent) are included in the
analysis reported in this finding.
The RBHAs report using HB2003 monies to pay
for training and consultation in preparation for
setting up the teams, as well as to pay for staff
positions and consumer services. For example,
NARBHA contracted with the South Carolina
Center for Innovation in Public Mental Health for
training and consulting services on a high-inten-sity
case management model for rural areas.
Both PGBHA and ValueOptions contracted with
experts to provide training on intensive case
management. In addition, three of the RBHAs used HB2003 monies to pay for inten-sive
case management team member positions. According to the RBHAs and
providers, team members provide direct services such as substance abuse and
vocational counseling, daily living skills training, and medication management.
New case management programs benefit consumers
Consumers treated by the new intensive case management teams made modest
improvements in their symptoms overall, but consumers with more severe dysfunc-tion
prior to entering the new program showed more marked gains.1 The Division and
the RBHAs identified several performance measures for evaluating the outcomes of
the intensive case management programs, as shown in Table 7 (see page 28).
Consumers who participated in the new programs, in contrast to a comparison
group, showed progress on most measures of functioning as a result of the intensive
case management they received. However, one RBHA’s consumers did not show
the same success as the other RBHAs’ consumers; therefore, the Division should
examine the causes for this RBHA’s lack of significant results.
1 The evaluation time frame spanned approximately 24 months from the time of earliest enrollment in February 2001
through January 31, 2003.
Office of the Auditor General
page 27
Table 6: Consumers Served by RBHAs’
Intensive Case Management Teams
As of December 31, 2002
RBHA
High-Intensity,
Community-Based
Teams
Supportive
Treatment
Teams
CPSA-3 44
CPSA-5 188
NARBHA 128
PGBHA 46
ValueOptions 94 1,721
Total 500 1,721
Source: Auditor General staff analysis of RBHA program enrollment rosters as of
December 31, 2002.
Consumers showed modest improvement in functioning—On average,
consumers in the HB2003 intensive case management teams showed modest gains
(about two points) on five different dimensions of the Arizona Level of Functioning
State of Arizona
page 28
Table 7: Progress of HB2003 Intensive Case Management
and Comparison Group
by Performance Measure1
July 1, 2000 through January 31, 2003
Performance Measure
and Expected Outcome
ValueOptions
High-Intensity, Community-Based
Case Management Compared to
ValueOptions Comparison Group
Arizona Level of Functioning Assessment (ALFA)
Family, living environment (reduced symptoms)2 􀂀􈀠
Feeling, affect, mood (reduced symptoms) 􀂀􈀠
Role performance (reduced symptoms) 􀁼􇰠
Self-care (reduced symptoms)2 􀂀􈀠
Thinking, cognition (reduced symptoms) 􀂀􈀠
Clinical Global Impression (CGI)
Global improvement (reduced symptoms) 􀁼􇰠
Severity of symptoms (reduced symptoms) 􀁺􇨠
Hospitalization (reduced hospitalizations)
Rate of admissions 􀁺􇨠
Length of stay NA
Arrests (reduced arrests) 􀀹􃤠
SF-12 Health Survey (reduced symptoms)2 􀂀􈀠
Symbol key:
􀁺􇨠 Improved much more than comparison group
􀂀􈀠 Improved more than comparison group
􀁼􇰠 No difference between groups
􀀹􃤠 Did not improve as much as comparison group
􀂵􋔠 Worsened more than comparison group
NA not available
1 See Appendix 2, Tables 15, 17, 19, 20, and 23 (pages a-xxii through a-xxx) for detailed results on each measure.
Differences greater than 10 percent of the total available points on the measure (5 out of 50 for ALFA, 0.7 out of 7 for
CGI) are shown as improved much more than the comparison group. Differences that were not statistically significant
are shown as no difference between groups.
2 Not a performance measure identified by the Division and the RBHAs for intensive case management.
Source: Auditor General staff analysis of program outcomes and assessment and service encounter data provided by the
Division and the RBHAs for the period July 1, 2000 through January 31, 2003, for HB2003 consumers; and
assessment and service encounter data provided by BHS for the period January 1, 2000 through April 30, 2002,
for the comparison group.
Assessment (ALFA), while a comparison group of consumers either stayed the same
or worsened. As shown in Table 13 (see Appendix 2, page a-xx), consumers who
entered the program at the severe dysfunction level made greater gains, progress-ing
to the moderate dysfunction level after spending at least 6 months in the new pro-gram.
In contrast, consumers who entered at the moderate level showed less
improvement, and those who entered at the slight dysfunction level lost ground on
most measures. Table 14 (see Appendix 2, page a-xxi) shows results by RBHA for all
five ALFA dimensions.
Comparison group consumers lost ground on the ALFA measures, on average, while
some in the high-intensity case management teams remained stable and others
slightly improved. The comparison group consisted of ValueOptions consumers who
were eligible for high-intensity case management, but instead received traditional
case management during the time auditors studied. As shown in Table 15 (see
Appendix 2, page a-xxii), comparison group consumers whose ALFA scores started
in the severe dysfunction range showed some improvement. However, their scores
remained in the severe range. In contrast, consumers on the high-intensity teams
who started in the severe range moved to the moderate range.
Consumers stable on symptom severity—A measure of symptoms, the
Clinical Global Impression (CGI), showed mixed results on two dimensions—global
improvement and severity of symptoms. The CGI measures the effects of
psyghotropic medications, and is completed by the clinician who monitors consumer
medications. On the global improvement dimension, only CPSA-3 and CPSA-5
showed positive results, while PGBHA’s consumers lost ground. One RBHA,
ValueOptions, showed improvement on the severity of symptoms dimension, and
this improvement was greater for these consumers than for the comparison group.
However, only one other RBHA’s consumers showed improvement. Tables 16 and 17
(see Appendix 2, pages a-xxiii through a-xxiv) summarizes results of the CGI.
Consumers reported improvement on health survey and reduced or
stable arrests—Generally, consumers showed improvement on the health survey
and reduction or stability in arrest measures, although consumers in the comparison
group showed greater improvement in self-reported arrests. Specifically:
􀁺􇩈 Health survey shows consumers reported improvement—Most consumers par-ticipating
in intensive case management programs showed some improvement
in their mental health as measured by the SF-12 health survey. The SF-12 asks
consumers direct questions about their health status, so it reflects their own per-ceptions
rather than a clinician’s. For example, consumers indicate how often
emotional problems interfere with their daily life. Results of this measure indicate
that, on average, consumers in nearly all the intensive case management teams
reported better mental health functioning after participating in the program for at
least 6 months. As shown in Table 18 (see Appendix 2, page a-xxv), RBHAs
showed improvement on the health survey. Consumers in the comparison
Consumers rated at
severe dysfunction lev-els
at enrollment
improved to moderate
dysfunction after 6
months.
Office of the Auditor General
page 29
group did not make similar improvements, as shown in Table 19
(see Appendix 2, page a-xxvi).
Consumers interviewed during the audit also told auditors that
they felt the new services had helped them. For example, con-sumers
reported that the team helps them function well in the
community, provides them with opportunities to socialize, and
helps them with their daily living needs. One consumer, who is
depressed, has epilepsy, and is an alcoholic, reported that his
involvement with an intensive case management team saved his life. He lives
independently with the help of the intensive case management team and
attends chemical dependency classes. Case managers and other team staff
auditors interviewed reported that intensive case management services help
clients stabilize, gain a better understanding of their illness and its impact, and
gain a better understanding of their symptoms.
􀁺􇩒 Reduced or stable arrests—The Division and the RBHAs identified a reduction
in arrests as a performance measure for the intensive case management pro-grams.
Two of the four RBHAs were able to provide complete enough informa-tion
for analysis. Overall, the total number of consumers arrested and the num-ber
of arrests prior to participation in HB2003 programs is low. ValueOptions’
high-intensity case management consumers showed a reduction in the number
of consumers arrested, but the comparison group consumers showed a greater
reduction (see Table 20, Appendix 2, page a-xxvii). The number of consumers
arrested remained stable at CPSA-3 and CPSA-5. ValueOptions’ high-intensity
case management consumers showed a reduction in the total number of
arrests, as shown in Table 21 (see Appendix 2, page a-xxviii), although again
the comparison group showed a greater reduction than this group. Although
arrest data is self-reported, the comparison group’s better performance on this
measure suggests that the Division should work with the RBHAs to determine
why the HB2003 programs did not have a greater impact. As a followup to this
analysis, the Division should analyze arrests for all four RBHAs, since only two
of the four RBHAs had sufficient data to be included in this analysis. The Division
could do this as part of its planned evaluation.
Hospitalizations remained stable for most groups—Auditors examined
hospitalization in two ways: the number of consumers hospitalized, and hospitaliza-tion
rate (the number of hospitalizations per 100 consumers). The number of con-sumers
hospitalized remained unchanged for most RBHAs and for the comparison
group. One RBHA, NARBHA, showed an increase in the number of consumers hos-pitalized,
as shown in Table 22 (see Appendix, page a-xxix). The rate at which con-sumers
were hospitalized per 100 consumers remained unchanged for two of the
four RBHAs, while the comparison groups deteriorated, as shown in Table 23 (see
Appendix 2, page a-xxx). One RBHA, CPSA-5, showed an improvement in the hos-pitalization
rate, and NARBHA’s rate worsened.
Consumers report that
the intensive case man-agement
teams help
them function well in the
community.
State of Arizona
page 30
Case Example
K.S., a PGBHA consumer, is a senior citizen who
has significant health problems. High-intensity
case management services have helped her stabi-lize
her mood so that she is more active and better
able to care for herself.
Arrests are a rare event
among HB2003 con-sumers.
Auditors could not compare length of stay in the two time periods because hospital-ization
records in the later period were incomplete. Because reducing hospitalization
is an important goal for intensive case management programs, the Division should
evaluate the programs’ impact on length of stay once data regarding discharge
dates is complete. This could be done as part of the Division’s planned evaluation.
Length of time in program did not affect ALFA results—Consumer out-comes
did not consistently improve when consumers in intensive case management
programs for longer periods were compared to those in the programs for less time.
For example, consumers in the ValueOptions high-intensity case management
teams for 12 months showed improvement on all three ALFA dimensions identified
as performance measures. However, consumers who had been in the teams for 18
months had little to no change in their functioning, on average, from their functioning
prior to entering the program. In contrast, consumers on ValueOptions’ supportive
treatment teams showed about the same improvement in functioning whether they
had been in the program for 6, 12, or 18 months. Further, at NARBHA, only con-sumers
who had been in the program for 18 months showed improvement on two of
five measures.
There are several possible reasons why the length of time in HB2003 intensive case
management programs did not consistently affect consumer symptoms. For exam-ple,
for many disorders, the long-term goal of treatment is to prevent future recur-rences
of symptoms, according to the American Psychiatric Association.1 The
Division’s Chief of Clinical Services stated that due to the cyclical nature of mental ill-ness,
at many points in treatment, prevention of regression and promotion of stabil-ity
can be considered a positive outcome. Further, division and RBHA officials have
also suggested that since recovery is a cyclical process in which consumers often
fluctuate between getting better and worse, the results may be capturing a recovery
cycle. As time goes on and consumers fluctuate in their functioning, the gains fluc-tuate
as well.
One RBHA’s consumers showed no benefits from program–—One
RBHA, PGBHA, had almost no positive results for its consumers in any of the out-comes
measured. Specifically, except for those with severe dysfunction on the fam-ily
and living environment dimension, PGBHA’s consumers did not improve on any
of the five ALFA measures examined. Further, they showed no change on one CGI
dimension and a slight worsening on the other, had no change in their SF-12 health
survey results, and no change in their hospitalization rate.
Division and PGBHA officials could not explain this lack of success. PGBHA estab-lished
high-intensity case management teams similar to those at ValueOptions but
did not show similar results. Although the number of consumers included in the ALFA
analysis was relatively small, as only 22 PGBHA consumers met the inclusion crite-
1 Gabbard, Glen O., M.D., Editor-in-Chief, Treatments of Psychiatric Disorders. Third Edition, 2001.
Office of the Auditor General
page 31
ria for this analysis, other analyses with comparable or even smaller numbers of par-ticipants
showed results. PGBHA’s consumers did not differ from ValueOptions’
high-intensity case management team participants in the beginning level of severity.
In addition, although PGBHA experienced difficulty in meeting staffing standards,
other RBHAs had the same difficulties, yet their consumers showed improvement.
The Division should examine the causes for the lack of significant results for
PGBHA’s consumers. Again, the Division could do this as part of its planned pro-gram
evaluation.
Program design has some elements of successful
models
The Division and the RBHAs jointly developed guidelines for HB2003 intensive case
management programs, using other successful intensive case management models
as a guideline. Research has shown that intensive case management programs that
contain certain program elements are associated with positive consumer outcomes.
During the planning stages prior to implementing the HB2003 programs, the Division
formed a literature review group to analyze research on intensive case management.
The group, which included staff from the Division, CPSA, PGBHA, and ValueOptions,
researched various intensive case management models, such as Wisconsin’s
Program of Assertive Community Treatment (PACT), and recommended program
guidelines.1 According to division and RBHA officials, the review group selected what
they believed were the most critical elements of best practice programs for its rec-ommendations,
including guidelines for community-based treatment, staff-to-con-sumer
ratios, and staffing levels. Further, the review group developed program-spe-cific
checklists for monitoring how well the intensive case management programs
adhered to the guidelines.
The RBHAs and their providers chose to implement their programs in different ways,
with some adhering more closely to the PACT and similar models than others. For
example, CPSA adapted the PACT model by leaving out requirements for daily team
meetings and a minimum percentage of consumer contact occurring in the commu-nity
instead of at clinical facilities. PGBHA adopted a rural version of Wisconsin’s
model, which allows the use of alternatives for crisis service instead of team member
services outside of business hours. In addition, only two providers told auditors that
they require a minimum number of consumer contacts per week, a common require-ment
in other models, but omitted from the guidelines developed by the Division and
the RBHAs.
As the RBHAs monitored their intensive case management programs, they found
that the programs struggled with consistently meeting staffing-level guidelines.
Division and the RBHAs
analyzed research on
intensive case manage-ment,
and selected ele-ments
for its program
recommendations.
1 NARBHA staff did not participate in the review group, but modeled their program after a rural high-intensity case man-agement
program in South Carolina.
State of Arizona
page 32
However, as the results generally indicate, the RBHAs and providers have success-fully
used creative approaches to meet the spirit of the guidelines. For example, the
guidelines require intensive case management teams to have a master’s-level team
leader, but these positions have been vacant at some reviews due to staff turnover.
To fulfill the team leader staffing guidelines, one service provider hired a different
master’s-level staff to serve as a clinical consultant to the team. In another case, a
provider did not have a vocational rehabilitation specialist on its intensive case man-agement
team. To remedy the problem, the provider trained one of its existing staff
members to fill the position.
RBHAs plan to continue programs
The RBHAs plan to continue HB2003 case management programs but may have to
modify them. In addition, some new programs based on the HB2003 model have
been developed:
􀁺􇩃 Continuation of current programs—The RBHAs plan to continue most intensive
case management programs; however, some programs will be modified once
HB2003 funds are no longer available. Some RBHAs’ teams will operate with
decreased staffing levels. For example, ValueOptions plans to pay for most of
its 39 HB2003-funded staff positions through its general budget, which consists
of Medicaid and non-Medicaid monies, once HB2003 monies run out. However,
programs can use the infrastructure, such as transportation and training mod-ules
paid for with HB2003 funds, to continue offering a model similar to HB2003.
According to the RBHAs, providers plan to use other fund sources for continued
services to non-Medicaid consumers and continue billing Medicaid for con-sumers
who are eligible.
􀁺􇩄 Development of new programs—ValueOptions has expanded its high-intensity
case management program to two other service sites—one in Glendale and one
in Mesa. These programs are modeled after the HB2003 program, but serve
non-HB2003 consumers.
Based on the results of its analysis, the Division should develop recommendations
and provide technical assistance to the RBHAs to improve their intensive case man-agement
programs.
Most HB2003 case
management programs
will continue with modifi-cations.
Office of the Auditor General
page 33
Recommendations
1. The Division should conduct its own impact analysis of HB2003 intensive case
management services. Specifically, the Division should:
a. Analyze arrests for all RBHAs that developed intensive case management
programs since only two of four RBHAs had enough complete information
to include in the Auditor General’s analysis.
b. Evaluate the impact on length of hospital stay once the data regarding dis-charge
dates is complete enough for analysis.
c. Examine the causes for the lack of significant results for PGBHA’s con-sumers.
The Division could conduct these analyses as part of the program evaluation it
plans to conduct once the RBHAs spend all of their HB2003 monies.
2. The Division should develop recommendations and provide technical assis-tance
to the RBHAs to improve their intensive case management programs
based on the results of its research.
State of Arizona
page 34
Rehabilitation activities have increased
Three RBHAs report using HB2003 monies to provide higher levels of vocational
rehabilitation and recovery support services for promoting recovery and greater self-sufficiency.
RBHAs responded to HB2003’s requirement to expand these services in
two main ways—integrating these services into existing intensive case management
programs, and expanding providers and services in their regions. Increases in reha-bilitation
activities at ValueOptions and CPSA helped increase participation from
slightly more than 24 percent to 40 percent. The Division and the RBHAs plan to sus-tain
the enhanced services, which are now covered by Medicaid because of the
Covered Services Project’s implementation in October 2001.
Rehabilitation services cover a broad spectrum and
involve two agencies
Consistent with the HB2003 legislation, the Division’s plan specifications allowed the
RBHAs to propose using HB2003 monies for recovery support and rehabilitation pro-grams.
Using $5.4 million in HB2003 monies, or nearly 16 percent of
the total spending as of June 30, 2003, three RBHAs have provided
greater vocational rehabilitation and recovery support services for
consumers.1 Recovery support consists of any services intended to
help consumers make progress in their recovery and includes serv-ices
that help consumers live in the community. These community
support services include the intensive case management and med-ication
management services discussed in Finding 2 (see pages 25
through 34), as well as “peer support” and “friend advocacy” pro-grams
that recruit, train, and support people to provide advocacy,
friendship, and support to persons with serious mental illness.
Rehabilitation services are also a part of recovery support and
include a wide array of services. These services range from teaching
1 CPSA, NARBHA, and ValueOptions reported using HB2003 monies for rehabilitation services to support the strategies
discussed. PGBHA used non-HB2003 resources to integrate rehabilitation into its HB2003 case management teams. The
fifth RBHA, Excel, reported that it used all its HB2003 monies for its housing programs and transportation.
Office of the Auditor General
FINDING 3
page 35
Recovery
Process helping people to participate
fully in their community despite their
disability. Care focuses on increasing
consumers’ ability to successfully
cope with life’s challenges, facilitating
recovery, and building resilience, not
just managing symptoms. Consumers
and their families have meaningful
choices about services and providers.
consumers basic community living skills, such as acquiring and developing the skills
necessary to manage a home or provide for basic daily living needs, to helping them
prepare to find and keep a job. Rehabilitation services may include encouraging con-sumers
to get involved in volunteering and other community activities such as clubs,
churches, and community organizations. They may also include attending club-houses
and consumer-run drop-in centers where consumers can meet to support
each other and socialize, volunteer, engage in transitional work activities or regular
employment, and actually oversee operations.
Rehabilitation services also include vocational rehabilitation services such as voca-tional
assessment, counseling, and job placement. These services involve the
Department of Economic Security’s Rehabilitation Services Administration (RSA). A
1993 interagency agreement facilitates the partnership between the Division and
RSA and sets forth the agencies’ contractual obligations. Under this agreement, the
behavioral health system provides rehabilitation services, including psychosocial
rehabilitation such as living skills, training, and clubhouses; consumer-operated serv-ices;
supported education; and extended supported employment. RSA provides
vocational assessment services such as career exploration, career-directed educa-tion
services, and employment-directed services per its federal mandate.1 For con-sumers
who are interested in RSA services, the two agencies combine resources
every year to leverage federal monies and provide career exploration, career-related
education, job placement, and other employment-related services. RSA can obtain
nearly $4 from federal funding for every $1 the Division contributes. In fiscal year
2003, the Division contributed more than $1.7 million in state monies of the RSA’s
nearly $8.2 million budget. Under the agreement, RSA agrees to use these combined
monies to develop and implement contracts with community providers to meet the
vocational needs of contracts to persons with serious mental illness. CPSA also com-bined
a portion of its HB2003 allocation with RSA federal monies to provide service
providers in Southern Arizona with RSA grants to establish new employment pro-grams.
RBHAs integrate and expand services
The RBHAs mainly pursued two strategies for improving rehabilitation and recovery
support services for their consumers: integrating rehabilitation planning into clinical
case management and expanding rehabilitation services availability in their respec-tive
geographic service areas. In addition, the Division and RSA have worked togeth-er
to promote recovery principles in rehabilitation service planning.
Rehabilitation integrated into intensive case management—To increase
consumers’ participation in rehabilitation activities, the RBHAs integrated rehabilita-tion
services into treatment planning for consumers who participate in intensive case
management teams. At three RBHAs—CPSA, PGBHA, and ValueOptions—rehabili-
Rehabilitation services
include more than voca-tional
training.
1 RSA is federally mandated to provide vocational services to persons with disabilities, including persons with serious men-tal
illness, in accordance with the Federal Rehabilitation Act of 1973.
State of Arizona
page 36
tation specialists or vocational specialists were placed as members of the case man-agement
teams. According to NARBHA officials, its teams rely on vocational spe-cialists
at provider agencies. Integrating rehabilitation and vocational staff into the
clinical treatment team is consistent with literature on high-intensity case manage-ment
models, which recommends including these positions as part of the treatment
team. The specialists help consumers identify their interests and encourage con-sumers’
participation in rehabilitation programs. They also refer consumers to RSA
and work with RSA’s vocational counselors for consumers who are interested in
seeking employment.
Range of providers and services expanded—Three RBHAs—
ValueOptions, NARBHA, and CPSA—report using HB2003 monies to expand the
array of rehabilitation services available in their regions. These efforts are consistent
with recovery principles calling for consumers to be able to choose from a variety of
services, activities, and programs as part of their treatment. Specifically:
􀁺􇨠 Expanded rehabilitation provider network in Maricopa County—In accordance
with the court-approved plan under Arnold v. Sarn, ValueOptions used HB2003
monies to expand the number of rehabilitation providers under contract.
ValueOptions originally had two providers, but was able to fund six more start-ing
July 1, 2001. One of the initial service providers—TripleR Behavioral Health—
operated two clubhouses in Maricopa County and provided supported employ-ment
services. The other provider offered work adjustment services. According
to ValueOptions’ officials, the expanded provider network allowed it to provide
additional rehabilitation and recovery support services such as home manage-ment
skills training, recovery training, work exploration, an “Art Awakenings” pro-gram,
supported education, and employment support services. ValueOptions
also used HB2003 monies to develop a new consumer-run drop-in center in
North Phoenix and enhance programs and facilities at existing drop-in centers.
Auditors were unable to identify how many people were involved in activities
prior to the HB2003 program because the Division did not require the RBHAs to
collect this information until April 2001. However, as of October 7, 2002,
ValueOptions reported that more than 3,700 of its nearly 14,000 enrolled mem-bers
were involved in some type of rehabilitation activity.
􀁺􇨠 New network of centers in Northern Arizona—NARBHA reported that
it used HB2003 monies to open the first consumer-operated recovery
centers in its service area. In partnership with RSA, NARBHA estab-lished
a network of five recovery centers under an organization called
NAZCARE (Northern Arizona Consumers Advancing Recovery and
Empowerment) headquartered in Prescott. According to NARBHA
officials, the first center, New Hope Recovery Center in Prescott,
opened in January 2002, and the remaining four opened between
January 2002 and October 2002.1 NAZCARE, a private, nonprofit
community service agency certified by ADHS, employs consumers to
Rehabilitation specialists
help consumers identify
their interests in avail-able
programs.
Office of the Auditor General
page 37
New Hope Recovery Center, Prescott, Arizona
1 According to NARBHA and NAZCARE officials, one drop-in center based in Snowflake, Arizona, closed in October 2003.
manage the centers and offer peer support. HB2003 dollars
funded staffing, training, operations, and facility development.
At these centers, consumers can socialize, work as managers
or peer specialists, and develop friendships and a support net-work.
NARBHA reports that close to 200 persons were involved
in the NAZCARE Centers during August and September 2003.
As of September 22, NAZCARE reported employing a total of
13 consumer staff, and expected to hire 5 more people to fill 18
total available positions.
􀁺􇩅 Enhanced consumer-run services and vocational system
evaluation in Southern Arizona—CPSA reported that it used
HB2003 monies to purchase computers and improve facilities
at two consumer-run clubhouses in Pima County. CPSA staff
indicated they also provided technical assistance and guidance
to the clubhouses to help them obtain status as community service agencies
that can bill services to Medicaid. CPSA also reported using HB2003 monies to
conduct a vocational system evaluation. CPSA initially contributed part of its
HB2003 monies to RSA to provide Southern Arizona service providers with RSA
grants for new employment programs. When RSA could not match HB2003
monies because of financial difficulties, they returned the unmatched monies to
CPSA. CPSA and RSA subsequently used these monies to hire a consultant to
assess the effectiveness of the rehabilitation service system in CPSA’s two geo-graphic
service areas. The consultant assessed the system’s strengths and
identified areas for improvement in policy, practice and program design, and
staff development. To continue these efforts, CPSA offered a training conference
in March 2004 and plans an ongoing system evaluation. CPSA hopes these
activities will help the region address the problems identified and improve serv-ice
delivery.
Division and RSA promote recovery principles—Two RBHAs are working
with the Division and RSA to teach consumers recovery principles, train them in dif-ferent
recovery strategies, and help them find employment as peer support special-ists.
Both NARBHA and ValueOptions are working with RSA to train consumers as
peer support specialists. These specialists are trained to teach recovery principles
and strategies, such as how to develop Wellness Recovery Action Plans (WRAP), a
recovery tool developed by Mary Ellen Copeland, a national expert in recovery for
persons with serious mental illness. Both RBHAs reported using HB2003 funding to
train clinicians and consumers in WRAP and other strategies designed to promote
recovery and self-sufficiency. Their service providers have also hired consumers who
have been trained as peer support specialists. For example, some service providers
have hired consumers to answer phone calls via warm lines, an alternative to a cri-sis
hot line.
State of Arizona
page 38
The Division, RBHAs,
and RSA help train con-sumers
to work as peer
support specialists.
Case example
L.B., a 59-year-old woman who is diagnosed with
schizophrenia, reported that she spent an entire year
in a psychiatric health facility and underwent elec-troshock
therapy prior to entering the HB2003 pro-gram.
Through a new recovery model program that
NARBHA established with HB2003 funding, L.B.
attended WRAP training. New Hope Recovery Center
in Prescott hired L.B. in June 2002 to offer peer sup-port
services for other consumers. Her symptoms
have greatly diminished, and she has not returned to
the psychiatric facility.
Division monitors programs against standards—The Division and the
RBHAs developed a core set of standards for each type of rehabilitation program,
based on a review of best practices. For example, they developed guidelines for the
clubhouse programs based in part on standards established by the International
Center for Clubhouse Development, located at the Fountain House clubhouse in
New York City. Two RBHAs—ValueOptions and NARBHA—reported monitoring their
subcontractors through such activities as site visits, clinical record reviews, interviews
with program managers, and interviews with consumers. The Division reviewed and
approved the RBHAs’ monitoring plans, including a checklist the RBHAs use to mon-itor
the ongoing adherence to the guidelines. CPSA reported monitoring its HB2003
rehabilitation activities in a different manner. For example, instead of conducting
fidelity site visits at the two clubhouses that received HB2003 support, CPSA staff
provided technical assistance to these two agencies, as noted previously. In addition,
CPSA reported that its vocational system evaluation far exceeds the Division’s fideli-ty
requirements.
Some participation in meaningful activities increased
Consumers in two RBHAS’ HB2003 programs increased their involvement in some
types of meaningful rehabilitation activities.1 Many people with serious mental illness
often have nothing meaningful to do during the day—they do not socialize with oth-ers,
attend school, or go to work. Thus, one important goal of the RBHAs’ rehabilita-tion
efforts under HB2003 was to increase their consumers’ activity levels.
Consumers at ValueOptions increased their participation in psychosocial and con-sumer-
run activities during the period auditors examined. State-wide, consumers
involved in these activities improved their interpersonal relations functioning as meas-ured
by the ALFA. Both CPSA-5 and ValueOptions’ consumers showed increased
participation in education, training, and transitional work
activities. Most consumers showed little or no increase in
paid employment, which may in part be due to RBHAs
placing greater emphasis on getting people involved in any
meaningful activity. A recent ValueOptions study found
HB2003 participants were more involved in meaningful
rehabilitation activities than other consumers, especially
psychosocial rehabilitation activities. Since gains did not
occur across all RBHAs, the Division should analyze reha-bilitation
activities at a later date, particularly the activity lev-els
at NARBHA and PGBHA. The Division could conduct
this follow-up analysis as part of its planned HB2003 eval-uation.
1 The evaluation time frame for rehabilitation services spanned 20 months from June 1, 2001 through January 31, 2003.
Auditors used a shorter time frame to control for the effect of a data conversion that occurred in April 2001, which
changed the way the RBHAs reported rehabilitation status.
Office of the Auditor General
page 39
Case Example
J.S., a ValueOptions consumer in his early 40s,
moved out of a supervisory care home into
HB2003-supervised housing. A shy, reserved
man with schizoaffective disorder, J.S. went
through the WRAP training and now takes the bus
to visit the TripleR clubhouse in central Phoenix.
J.S. is very happy with his clinical team and likes
the clubhouse because of all the friends he has
made. He has also expressed interest in learning
about computers.
Increase in meaningful activities varies by type of activity—More con-sumers
became involved in activities classified as psychosocial rehabilitation and
consumer-run services than in education, training, or transitional work activities, and
full- or part-time employment. Specifically,
􀁺􇩉 Involvement in psychosocial rehabilitation and consumer-run activities
increased—HB2003 program participants at CPSA-5, NARBHA, and
ValueOptions increased their involvement in activities intended to improve
socialization and interpersonal functioning.1 These include social rehabilitation,
skills training, clubhouse programs, volunteer work, and consumer-run drop-in
centers (see Appendix 2, Table 24, page a-xxxi). Consumers at CPSA-5 and
ValueOptions who were involved in psychosocial and consumer-run activities
improved in their interpersonal relations functioning after spending at least 180
days in HB2003 programs. (See Appendix 2, Table 25, page a-xxxiii).
􀁺􇩌 Limited increase in education, training, and transitional work activities—
Consumers on CPSA-5’s high-intensity case management teams and those in
ValueOptions traditional case management increased their participation in edu-cation,
training, and transitional work activities, as shown in Table 26 (see
Appendix 2, page a-xxxiii). At CPSA-5, the number of consumers involved in
these activities was relatively high before HB2003, and doubled, with its con-sumers
most often entering transitional employment programs. ValueOptions
invested HB2003 monies directly in supported education services, which offer
financial assistance for community college courses, GED preparation, and other
education. ValueOptions offered the services to all consumers, including those
participating in high-intensity, supportive treatment, and traditional case man-agement
teams.
􀁺􇩌 Little or no change in employment—State-wide, the number of consumers
employed either full- or part-time remained low during the period examined.
Only ValueOptions’ supportive treatment teams showed an increase in employ-ment
(see Appendix 2, Table 27, page a-xxxiv). According to the Division, the
HB2003 programs focused primarily on those individuals who were not express-ing
an immediate desire to enter the workforce. As the RBHAs expanded their
rehabilitation services, they emphasized getting people involved in any mean-ingful
activity, rather than focusing exclusively on paid employment. Although
other rehabilitation activities may benefit a person’s recovery, research suggests
that they may not directly lead to paid employment. Paid employment is the
highest level of independence, but moving people with serious mental illness
toward greater self-sufficiency may not move them toward paid employment
unless paid employment is a designated treatment or program goal. If compet-itive
employment is the ultimate goal, research on the employment of persons
with serious mental illness states that efforts should be focused on this specific
goal to achieve a successful outcome.
1 Although CPSA-5 and NARBHA showed statistically significant increases in participation, the actual number of con-sumers
involved—only 11 between both RBHAs—is too small to be meaningful when the total number of consumers for
those RBHAs is considered.
State of Arizona
page 40
Research also suggests that rapid placement in competitive employment and
providing time-unlimited, supported employment services is the most effective
strategy for improving employment outcomes, although more research is rec-ommended.
Federal law defines supported employment services as ongoing
support services and other appropriate services needed to support and main-tain
an individual in competitive work in integrated work settings.
In addition to analyzing consumers’ rehabilitation activity status at the time of assess-ment,
auditors also interviewed consumers who told auditors how the activities have
helped them. For example, consumers at a CPSA clubhouse in Tucson said volun-teering
at the clubhouse helped them feel needed and that the clubhouse could not
be run without them. The clubhouse director explained that the consumers were
building skills and learning to engage with the community. In addition, auditors inter-viewed
four Arizona State Hospital patients who spend part of their days in a
ValueOptions’ work program. One said, “They gave me something to concentrate
on, they gave me hope.” Another ValueOptions consumer said her job at a thrift store
is the first job she has had, and it helps her to be proud and build her self-esteem.
ValueOptions study found similar results—In October 2002, ValueOptions
compared activity and employment levels among consumers at its 21 clinical sites.
This research found higher rehabilitation activity levels at the three HB2003 sites
when compared to the other 18 sites, especially in the psychosocial rehabilitation
activity category.
ValueOptions officials attributed some of the consumers’ increased participation lev-els
to higher rehabilitation specialist staffing. According to ValueOptions, as of
August 2003, each clinical team at the HB2003 sites had a rehabilitation specialist,
for a total of 13 specialists available to consumers at those three sites. In contrast,
ValueOptions reported 20 total positions across 18 non-HB2003 sites, with most sites
employing just one rehabilitation specialist and two sites with no rehabilitation spe-cialist
at all. One of the plaintiffs’ attorneys in Arnold v. Sarn identified the addition of
rehabilitation specialists at ValueOptions as one of the most positive changes in
years.
The Division should analyze activity levels among RBHAs—Although
overall a

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A REPORT
TO THE
ARIZONA LEGISLATURE
Debra K. Davenport
Auditor General
Behavioral Health
Services’ HB2003
Funding for Adults with
Serious Mental Illness
Performance Audit Division
APRIL • 2004
REPORT NO. 04-03
Performance Audit
The Auditor General is appointed by the Joint Legislative Audit Committee, a bipartisan committee composed of five senators
and five representatives. Her mission is to provide independent and impartial information and specific recommendations to
improve the operations of state and local government entities. To this end, she provides financial audits and accounting servic-es
to the State and political subdivisions, investigates possible misuse of public monies, and conducts performance audits of
school districts, state agencies, and the programs they administer.
The Joint Legislative Audit Committee
Representative John Huppenthal, Chair Senator Robert Blendu, Vice Chair
Representative Tom Boone Senator Gabrielle Giffords
Representative Ken Clark Senator Peter Rios
Representative Ted Downing Senator Thayer Verschoor
Representative Steve Yarbrough Senator Jim Weiers
Representative Jake Flake (ex-officio) Senator Ken Bennett (ex-officio)
Audit Staff
Shan Hays, Manager and Contact Person
Monique Cordova, Team leader Joseph McKersie
Aaron Cook Kristie Waldron
Copies of the Auditor General’s reports are free.
You may request them by contacting us at:
Office of the Auditor General
2910 N. 44th Street, Suite 410 • Phoenix, AZ 85018 • (602) 553-0333
Additionally, many of our reports can be found in electronic format at:
www.auditorgen.state.az.us
2 9 1 0 N O R T H 4 4 t h S T R E E T • S U I T E 4 1 0 • P H O E N I X , A R I Z O N A 8 5 0 1 8 • ( 6 0 2 ) 5 5 3 - 0 3 3 3 • F A X ( 6 0 2 ) 5 5 3 - 0 0 5 1
DEBRA K. DAVENPORT, CPA
AUDITOR GENERAL
STATE OF ARIZONA
OFFICE OF THE
AUDITOR GENERAL
WILLIAM THOMSON
DEPUTY AUDITOR GENERAL
April 26, 2004
Members of the Arizona Legislature
The Honorable Janet Napolitano, Governor
Catherine R. Eden, Ph.D., Director
Arizona Department of Health Services
Transmitted herewith is a report of the Auditor General, a Performance Audit of the Department
of Health Services, Behavioral Health Services’ HB2003 Funding for Adults with Serious Mental
Illness. The report is in response to Laws 2000, Fifth Special Session, Chapter 2, §§1 and 5
which established the funding, and required the Office of the Auditor General to examine the
Department’s success in using the monies to meet agreed-upon performance standards. I am
also transmitting with this report a copy of the Report Highlights for this audit to provide a quick
summary for your convenience.
As outlined in its response, the Department of Health Services agrees with all three findings and
plans to implement or implement in a different manner all of the recommendations.
My staff and I will be pleased to discuss or clarify items in the report.
The report will be released to the public on April 27, 2004.
Sincerely,
Debbie Davenport
Auditor General
Enclosures
The Office of the Auditor General has conducted a performance audit examining the
results of appropriating approximately $42 million in special one-time funding for
services to persons with serious mental illnesses. This funding, known as House Bill
2003 (HB2003) funding, was specifically established in Laws 2000, Fifth Special
Session, Chapter 2, §§1 and 5. This legislation also requires the Office of the Auditor
General to examine the success in using the monies to meet agreed-upon perform-ance
standards.1 The program established by the legislation ends on July 1, 2005,
pursuant to Arizona Revised Statutes §36-503.02.
The money was appropriated to the Department of Health Services to provide hous-ing,
vocational rehabilitation, and other support services to people with schizophre-nia,
delusional disorders, or any of several other conditions. The Department’s
Division of Behavioral Health Services (Division) distributed most of the monies to the
five Regional Behavioral Health Authorities (RBHAs) that administer mental health
programs in the State. To obtain the money, each RBHA had to develop a plan con-sistent
with the Division’s specifications, including a list of performance standards for
evaluating accomplishments. Examples of performance standards include reduction
in symptoms, hospitalization, jail and arrests, and substance abuse. The standards
also include increases in housing stability, safety, social adjustment, recovery, and
vocational participation. As of June 30, 2003, the RBHAs had spent more than 82
percent of the total amount allocated to them. Over 90 percent of the monies spent
as of June 30, 2003, was spent in three main areas: housing (40 percent), intensive
case management (35 percent), and additional rehabilitation services (nearly 16 per-cent).
The remaining monies were spent on RBHA administrative expenditures and
such items or services as vehicles for transporting consumers, expanding evaluation
programs, and videoconferencing equipment for expanding service networks. 2
The Division requires all of the monies to be spent by January 1, 2005. According to
division officials, they plan to conduct an evaluation of the programs that the RBHAs
developed with their HB2003 monies once the RBHAs have spent all of their HB2003
monies.
1 Laws 2000, Fifth Special Session, Chapter 2, §5 also appropriated $20 million for funding children’s behavioral health
services. A separate performance audit of the House Bill 2003 children’s services program was released in December
2002 (Report No. 02-12).
2 The Division and the RBHAs refer to persons receiving services as consumers.
Office of the Auditor General
SUMMARY
page i
Consumers benefited from housing programs (see
pages 13 through 23)
The five RBHAs reported using a total of $13.6 million in HB2003 monies, or approx-imately
40 percent of the total spent as of June 30, 2003, to develop housing and
related programs. Research shows that stable housing is an important factor in a
consumer’s recovery from mental illness, although persons with serious mental ill-ness
commonly cannot attain suitable housing and may lose their homes and
become homeless. Research also shows that people with a serious mental illness
need housing that is coordinated with other support services. Through an intera-gency
agreement, the Arizona Department of Housing helped the RBHAs identify
and acquire properties. In all, the five RBHAs reported they bought or built housing
and apartments on 39 sites in 21 cities around Arizona, and created housing space
for 334 individuals. Two RBHAs—ValueOptions and NARBHA—developed super-vised
housing and independent living options, while the other three RBHAs devel-oped
independent housing options only. This housing will continue to be available
after the HB2003 program ends. Two RBHAs—ValueOptions and PGBHA—also
used part of the monies for programs that help people stay in the housing they
already have.
Consumers who lived in the new housing for at least 6 months improved in their men-tal
health functioning and independence, and reported satisfaction with the housing.1
Specifically, at ValueOptions, consumers made greater gains on several measures of
functioning than consumers on a waiting list for new housing. For example, they
improved in measures of family and living environment, interpersonal relations, sub-stance
abuse, self-care, and feeling and mood. At Excel, consumers made gains
only on the substance abuse measure of functioning. Further, results varied accord-ing
to consumers’ beginning mental health functioning level, with the greatest gains
occurring among ValueOptions consumers who had the most severe dysfunction.
Additionally, consumers at both RBHAs generally either maintained or increased their
level of independence. Finally, most consumers interviewed during the audit report-ed
satisfaction with their new housing.
Since three RBHAs’ new-housing consumers generally had not lived in their homes
long enough to be included in this audit’s analysis, the Division should assess con-sumers’
progress at these RBHAs after their consumers have lived in housing for at
least 6 months. The Division should also determine the housing program’s impact on
hospitalization and arrests. Although these two measures were identified in the
Division’s list of performance standards, auditors could not draw conclusions about
them because they were such rare events among the population examined. Finally,
the Division should work with Excel to determine what outcomes should be expect-ed
for consumers in independent housing, and analyze the impact of Excel’s hous-
State of Arizona
page ii
1 The evaluation time frame spanned approximately 24 months from the first time a consumer moved into HB2003 hous-ing
in February 2001 through January 31, 2003.
ing program against those outcomes. The Division could conduct these analyses as
part of the HB2003 program evaluation that it plans to conduct once all HB2003
monies are expended. The Division should use its research results to develop rec-ommendations
and provide technical assistance to the RBHAs to improve their
housing programs.
Consumers show modest gain from intensive case man-agement
programs (pages 25 through 34)
Four of the five RBHAs reported using $12 million, or 35 percent of total spending as
of June 30, 2003, to develop intensive case management teams to provide con-sumers
with a range of services, including substance abuse and vocational coun-seling,
medication management, and life skills training. The teams differ from tradi-tional
case management in their staffing structure, caseload size, and frequency of
contact. In addition, team members provide many services directly instead of coor-dinating
all services through other providers. Several research studies on Assertive
Community Treatment (ACT), a form of intensive case management, have linked this
approach with fewer hospitalizations, less severe symptoms, and increased life sat-isfaction.
As of December 31, 2002, more than 2,200 consumers, or about 8 percent
of the adults with serious mental illness in the behavioral health system, had received
assistance from the new teams.
Overall, consumers who participated in these new intensive case management pro-grams
made modest improvements in their functioning level, while consumers in a
comparison group either stayed the same or worsened.1 Consumers with more
severe dysfunctions prior to entering the program showed the greatest gains.
Symptoms and hospitalization remained stable for most groups, and self-reported
arrests improved but not as much as expected. However, consumers’ own assess-ments
of their mental health status improved, and consumers interviewed during the
audit told auditors that they felt the new services had helped them. The length of time
consumers remained in the program did not affect functioning level results. Although
the new programs resulted in modest improvement for consumers at most RBHAs,
PGBHA’s consumers showed little change from services provided through HB2003
during the 24-month evaluation time frame. In conjunction with the recommendation
to analyze arrests for consumers who lived in HB2003 housing, the Division should
also analyze arrests for consumers who participated in the intensive case manage-ment
programs, since auditors could assess results for only two of the four RBHAs
that developed these programs. The Division should also evaluate the program’s
impact on length of hospital stay, since discharge data was too limited for auditors
to conduct this analysis. Finally, the Division should examine the causes for the lack
1 The evaluation time frame spanned approximately 24 months from the time of earliest enrollment in February 2001
through January 31, 2003.
Office of the Auditor General
page iii
of significant results for PGBHA’s consumers. The Division could conduct these
analyses as part of its planned program evaluation, and should develop recommen-dations
and provide technical assistance to the RBHAs to improve their intensive
case management programs.
Rehabilitation activities have increased (see pages 35
through 43)
Using $5.4 million in HB2003 monies, or nearly 16 percent of the total spending as
of June 30, 2003, according to their reports, three RBHAs—ValueOptions, CPSA,
and NARBHA—provided greater vocational rehabilitation and recovery support serv-ices
for consumers. These services range from teaching consumers basic commu-nity
living skills to helping them prepare to find and keep a job. RBHAs mainly pur-sued
two strategies for improving rehabilitation and recovery support services:
integrating rehabilitation planning into clinical case management and expanding
rehabilitation service availability in their respective service areas. For example, some
RBHAs have established consumer-run drop-in centers where consumers can meet
to support each other and socialize, volunteer, work, and actually oversee operations.
The Rehabilitation Services Administration (RSA) of Arizona’s Department of
Economic Security has also been involved in these efforts. For example, two RBHAs
are working with the Division and RSA to teach consumers recovery principles and
help them find employment as peer support specialists.
As a result of these efforts, consumers in two RBHAs increased their involvement in
some types of meaningful community activities.1 Consumers at ValueOptions
increased their involvement in psychosocial rehabilitation and consumer-run activi-ties.
Some consumers at ValueOptions and CPSA-5 who were involved in those
activities improved their interpersonal relations functioning. In addition, ValueOptions
and CPSA-5 consumers increased participation in education, training, and transi-tional
work activities. However, most consumers showed little or no increased partic-ipation
in paid employment. Research on the employment of persons with serious
mental illness states that if competitive employment is the ultimate goal, then reha-bilitation
efforts should be directly focused on competitive employment to achieve a
successful outcome. According to the Division, the HB2003 programs focused pri-marily
on those individuals who were not expressing an immediate desire to enter the
workforce, and emphasized getting people involved in any meaningful rehabilitation
activity, rather than focusing exclusively on paid employment.
The Division should analyze rehabilitation activity levels at a later date to determine if
ValueOptions and CPSA consumers continue to increase their activity levels, and
whether the other RBHAs’ consumers eventually increase their activity levels. The
Division could do this as part of its planned program evaluation, and should provide
1 The evaluation time frame for rehabilitation services spanned 20 months from June 1, 2001 through January 31, 2003.
Auditors used a shorter time frame to control for the effect of a data conversion that occurred in April 2001 that changed
the way the RBHAs reported rehabilitation status.
State of Arizona
page iv
technical assistance to the RBHAs to identify and implement any needed program
changes to increase activity levels in the different geographic service areas.
According to division and RBHA representatives, most of the HB2003 rehabilitation
system enhancements will be sustainable in the future because they have been
added as covered services under Medicaid. This change took place in October
2001. HB2003 monies were used to help service providers set up systems to report
these services to the RBHAs and pay for services for persons who are not Medicaid-eligible.
Office of the Auditor General
page v
State of Arizona
page vi
Office of the Auditor General
TABLE OF CONTENTS
continued
page vii
1
13
13
15
17
21
23
25
25
27
32
33
34
35
35
36
39
43
43
Introduction & Background
Finding 1: Consumers benefited from housing
programs
Housing important for consumers with serious mental illness
Housing and housing support provided
Consumers benefit from housing programs
Programs appear well-designed and help address housing gap
Recommendations
Finding 2: Consumers show modest gain from
intensive case management programs
Intensive case management teams developed
New case management programs benefit consumers
Program design has some elements of successful models
RBHAs plan to continue programs
Recommendations
Finding 3: Rehabilitation activities have increased
Rehabilitation services cover a broad spectrum and involve two
agencies
RBHAs integrate and expand services
Some participation in meaningful activities increased
Covered Services Project will help sustain services
Recommendation
State of Arizona
TABLE OF CONTENTS
page viii
Appendix 1:
HB2003 Performance Measures
Appendix 2:
Summary
Design and methods
Appendix 3:
Bibliography
Agency Response
Figures:
1 Regional Behavioral Health Authorities
Program Fund Allocations
Through June 30, 2005
2 House Bill 2003 Housing Locations by
Regional Behavioral Health Authorities
As of June 30, 2003
3 Rehabilitation Activity Levels
Before and After Consumers’ Participation
in HB2003 Programs
June 1, 2001 through January 31, 2003
a-i
a-vii
a-vii
a-ix
a-ix
a-xxxix
a-xlv
4
15
42
continued
Office of the Auditor General
TABLE OF CONTENTS
continued
page ix
5
6
8
16
18
27
28
a-xv
Tables:
1 Performance Measures
for Evaluating Outcomes of
HB2003 Programs for Adults with Serious Mental Illness
2 HB2003 Serious Mental Illness (SMI) Program Allocations
and Expenditures
From Program Inception through June 30, 2003
(Unaudited)
3 Number of HB2003 Consumers with a Serious Mental Illness
Served
As of December 31, 2002
4 Number of HB2003 Housing Consumers by RBHA
February 1, 2001 through September 30, 2003
5 Housing
Progress of HB2003 Housing Consumers
and Two Comparison Groups
by Performance Measure
July 1, 2000 through January 31, 2003
6 Consumers Served by RBHAs’
Intensive Case Management Teams
As of December 31, 2002
7 Progress of HB2003 Intensive Case Management
and Comparison Group
by Performance Measure
July 1, 2000 through January 31, 2003
8 Housing
Average ALFA Scores for Three RBHAs
Before and After Residence in HB2003 Housing
July 1, 2000 through January 31, 2003
State of Arizona
TABLE OF CONTENTS
page x
Tables (cont’d):
9 Housing
Differences in Average ALFA Scores for Two RBHAs
July 1, 2000 through January 31, 2003
10 Housing
Comparison of Average ALFA Changes for HB2003 Consumers
and ValueOptions’ Waiting List Consumers
July 1, 2000 through January 31, 2003
11 Housing
Differences of Average CGI Scores for HB2003 Consumers at
Three RBHAs Compared to ValueOptions’ Waiting List Consumers
July 1, 2000 through January 31, 2003
12 Housing
Differences of Average CGI Scores for HB2003
Consumers at Two RBHAs
July 1, 2000 through January 31, 2003
13 Case Management
Differences in Average ALFA Scores
Before and After Participation
in HB2003 Case Management Teams
July 1, 2000 through January 31, 2003
14 Case Management
Differences in Average ALFA Scores for Four RBHAs
July 1, 2000 through January 31, 2003
a-xvi
a-xvii
a-xviii
a-xix
a-xx
xxi
continued
Office of the Auditor General
TABLE OF CONTENTS
continued
page xi
a-xxii
a-xxiii
a-xxiv
a-xxv
a-xxvi
Tables (cont’d):
15 Case Management
Differences in Average ALFA Scores
for ValueOptions’ HB2003 High-Intensity, Community-Based
Team Consumers Compared to Other ValueOptions’ Consumers
July 1, 2000 through January 31, 2003
16 Case Management
Differences of Average CGI Scores
for HB2003 Consumers at Four RBHAs
July 1, 2000 through January 31, 2003
17 Case Management
Differences in Average CGI Scores for ValueOptions’
HB2003 High-Intensity, Community-Based Team Consumers
Compared to Other ValueOptions Consumers
July 1, 2000 through January 31, 2003
18 Case Management
Differences in Average MCS-12 Scores
Before and After Participation
in HB2003 Case Management Teams
July 1, 2000 through January 31, 2003
19 Case Management
Differences in Average SF-12 Scores for ValueOptions’ HB2003
High-Intensity, Community-Based Team Consumers Compared
to Other ValueOptions’ Consumers
July 1, 2000 through January 31, 2003
State of Arizona
TABLE OF CONTENTS
page xii
Tables (cont’d):
20 Case Management
Consumers in Two RBHAs Arrested Before and After
Participating in HB2003 Case Management Teams
Compared to Other ValueOptions Consumers
July 1, 2000 through January 31, 2003
21 Case Management
Consumers’ Arrest Rate in Two RBHAs Before and After
Participation in HB2003 Case Management Teams Compared
to Other ValueOptions Consumers
July 1, 2000 through January 31, 2003
22 Case Management
Consumers Hospitalized Before and After Participating
in HB2003 Case Management Teams Compared to Other
ValueOptions’ Consumers
July 1, 2000 through January 31, 2003
23 Case Management
Hospitalization Rate Before and After Participating In HB2003
Case Management Teams Compared to Other ValueOptions
Consumers
July 1, 2000 through January 31, 2003
24 Rehabilitation
Consumers Enrolled in Psychosocial and Consumer-Run
Rehabilitation Activities Before and After Participation
in HB2003 Programs
June 1, 2001 through January 31, 2003
a-xxvii
a-xxviii
a-xxix
a-xxx
a-xxxi
continued
Office of the Auditor General
TABLE OF CONTENTS
page xiii
concluded
a-xxxii
a-xxxiii
a-xxxiv
a-xxxv
a-xxxvii
Tables (concl’d)
25 Rehabilitation
Average ALFA-Interpersonal Relations Scores for HB2003
Consumers Enrolled in Psychosocial and Consumer-Run
Rehabilitation Activities
June 1, 2001 through January 31, 2003
26 Rehabilitation
Consumers Enrolled in Educational, Training, and Transitional
Work Programs Before and After Participation in
HB2003 Programs
June 1, 2001 through January 31, 2003
27 Rehabilitation
Consumers Employed Before and After Participation
in HB2003 Programs
June 1, 2001 through January 31, 2003
28 Characteristics of HB2003 Housing Consumers
Compared to ValueOptions’
Waiting List Consumers
29 Characteristics of HB2003 Case Management Consumers
Compared to Other ValueOptions’ Consumers
State of Arizona
page xiv
The Office of the Auditor General has conducted a performance audit examining the
results of appropriating approximately $42 million in special one-time funding for
services to persons with serious mental illnesses. This funding, known as House Bill
2003 (HB2003) funding, was specifically established in Laws 2000, Fifth Special
Session, Chapter 2, §§1 and 5. This legislation also requires the Office of the Auditor
General to examine the success in using the monies to meet agreed-upon perform-ance
standards.1 The program established by the legislation ends on July 1, 2005,
pursuant to Arizona Revised Statutes §36-503.02.
Monies to be used for persons with serious mental illness
Under the approved legislation, the Legislature initially appropriated $50 million from
the State General Fund’s tobacco litigation settlement account to the Department of
Health Services in fiscal 2001. In 2002, the Legislature
reduced the total allocation by $9.5 million. The
Department’s Division of Behavioral Health Services
(Division) reported that it returned the money but added
$1.6 million from accumulated interest earned on the
appropriated funding, resulting in a new total amount of
$42.1 million. According to the legislation, the one-time,
nonreverting funding was to be used for housing, voca-tional
rehabilitation, and other recovery support servic-es
for persons who have a serious mental illness. The
legislation also requires the Department of Health
Services to design services to help these persons
achieve the highest level of self-sufficiency and to
develop performance standards to measure its success
in using the HB2003 monies. Finally, the monies were to be used to supplement and
not supplant existing and future appropriations.
1 Laws 2000, Fifth Special Session, Chapter 2, §5 also appropriated $20 million for funding children’s behavioral health
services. A separate performance audit of the House Bill 2003 children’s services program was released in December
2002 (Report No. 02-12).
Office of the Auditor General
INTRODUCTION
& BACKGROUND
page 1
Serious Mental Illness—Severe, chronic mental illness
(such as schizophrenia) that interferes with a person’s
ability to function in society.
Recovery Support—Services that help consumers gain
control over their mental illness by learning to manage
symptoms, recognize and avert crises, seek help when
needed, and attain their highest level of self-sufficien-cy.
For example, these services include teaching con-sumers
to use a Wellness Recovery Action Plan
(WRAP).
According to the bill’s primary sponsor, the HB2003 monies were intended to allow
the Department to show that additional funding could make a difference in its ability
to serve adults with serious mental illness. Arizona has had long-standing challenges
meeting these needs. In part as a result of a 1981 lawsuit, several reports have exam-ined
Arizona’s behavioral health system and identified needed improvements.1 The
Arnold v. Sarn lawsuit was filed on behalf of people with serious mental illness in
Maricopa County and alleged that the State and Maricopa County failed to provide
them adequate community mental health services as required by law.
One report from 1991—a year when state-wide funding for serious mental illness
totaled $57 million—estimated the total cost of complying with the lawsuit in
Maricopa County for fiscal years 1991 through 1995 at $240 million.2 Funding for
services has increased substantially since the lawsuit, most notably through the addi-tion
of federal Medicaid monies beginning in fiscal year 1990. Still, a 1998 agreement
related to the lawsuit and a 1999 Legislative Task Force report have continued to
identify unmet needs for serving adults with serious mental illness.
HB2003 planning reflects system needs
The HB2003 legislation targets three areas—community housing, vocational rehabil-itation,
and other recovery support services—all of which are areas identified as hav-ing
unmet needs. Recent agreements related to the Arnold lawsuit have focused on
these areas, and the Division’s plans for using the HB2003 monies attempted to
address those needs. For example, a 1998 agreement with the plaintiffs required the
Division to develop strategic plans for housing and vocational and substance abuse
services, and a consultant report required by the agreement identified service needs
in housing, recovery support, and rehabilitation. The Division used the strategic plans
and consultant’s report in identifying HB2003 program service categories and per-formance
measures. Similarly, in 2000, the Division and its Maricopa County
Regional Behavioral Health Authority (RBHA) developed a case management plan
for Maricopa County to replace a plan developed by the Court Monitor. Case man-agement
is a type of recovery support. The Division directed the RBHA to be con-sistent
with this plan in developing its proposal for using HB2003 monies in the
County.
Other reports have also identified needs in those areas and influenced plans for the
HB2003 monies. Specifically, a 1999 service gap analysis for Maricopa County
reported that stakeholders identified three service priorities for persons with serious
mental illness: 1) more aggressive case management, 2) availability of meaningful
1 160 Ariz. 593; 775 P.2d 521; 1989, Maricopa County C-432355.
2 The Blueprint: Implementing Services to the Seriously Mentally Ill, which was the implementation plan intended to ensure
that the court’s judgment would be fully implemented. The Blueprint was issued by the Department of Health Services
and the Maricopa County Board of Supervisors.
State of Arizona
page 2
daily activities, including consumer-run clubhouses, businesses, and social activities,
and 3) additional housing options, including a full continuum of housing that includes
home-based services.1 All three priorities were included in the HB2003 spending
plans. Further, a Legislative Task Force in 1999 noted the need for a state-wide men-tal
health system that provides a continuum of care including housing, rehabilitation,
and vocational services.
A 1999 United States Supreme Court decision and subsequent Presidential
Executive Order also support Arizona’s decision to spend money on improving com-munity-
based mental health services. In Olmstead v. L.C.,2 the court held that unnec-essary
segregation of individuals with disabilities in institutions may constitute dis-crimination
based on disability. In August 2001, three Arizona state agencies—the
Departments of Health Services and Economic Security and the Arizona Health Care
Cost Containment System—completed Arizona’s Olmstead Plan. The plan and its
March 2003 revision described activities that were underway to improve Arizona’s
community-based system, including establishing active community treatment case
1 ValueOptions conducted the gap analysis as part of its service implementation after the Department awarded it the
Regional Behavioral Health Authority (RBHA) contract for Maricopa County in 1998. Stakeholders included officials and
staff of the former RBHA, ComCare, consumers, healthcare providers, state and city agency representatives, and advo-cates.
2 Olmstead v. L.C., 119 S.Ct. 2176 (1999).
Office of the Auditor General
page 3
Arnold v. Sarn lawsuit selected events
1981: A public fiduciary named Arnold files suit on behalf of people with serious mental ill-ness
in Maricopa County, alleging the State did not comply with A.R.S. §36-
550.01(A) which requires it to provide an array of community-based mental health
services to people with serious mental illness.
1986: Maricopa County Superior Court finds on behalf of the plaintiffs.
1995: Exit stipulation sets out terms for fully satisfying the lawsuit, including development
of community living arrangements, appropriate support for people living in the
Arizona State Hospital, and diversion of individuals from the Maricopa County Jail.
1998: Agreement with plaintiffs requires Department of Health Services to create strategic
plans for housing, vocational services, and substance abuse services, and to retain
Human Services Research Institute (HSRI) as a consultant to help determine type,
intensity, and amount of services necessary to meet class members’ needs.
1999: HSRI report identifies needed services, including housing, recovery support, and
rehabilitation.
2000: Case management plan developed for Maricopa County.
management teams, expanding consumer-run services, and using HB2003 monies
for services such as housing and vocational rehabilitation.1
Program monies distributed to RBHAs
The Division allocated approximately $41.6 million of
the $42.1 million in HB2003 funds to the State’s
Regional Behavioral Health Authorities (RBHAs) for
programs and services. The Division contracts with five
RBHAs to provide behavioral health services in their
geographic service areas, and allocated the HB2003
monies to the RBHAs based on service area popula-tion.
Four RBHAs subcontract with behavioral health
service providers in a manner similar to health mainte-nance
organizations, and the fifth, the Excel group in
Yuma, directly provides most services in its region.
Figure 1 shows the five RBHAs, the six geographic
areas they serve, and their HB2003 funding allocations.
Of the $527,000 not transferred to the RBHAs, the
Division paid $227,000 to the Department of Housing
for services provided to RBHAs in acquiring housing
units and, as required by the legislation, transferred
$300,000 to the Office of the Auditor General for this
audit.
Following legislation passage, the Division issued
HB2003 Plan Specifications to the five RBHAs. To
obtain HB2003 monies, each RBHA had to develop a
plan consistent with the specifications. The RBHAs
could propose using the monies to develop housing for
consumers with serious mental illness, and/or to devel-op
recovery support and rehabilitation services to help
consumers achieve their highest level of self-sufficien-cy.
The specifications included an evaluation compo-nent
that listed performance measures for each type of
program (see Table 1, page 5). As required by the leg-islation,
the Office of the Auditor General reviewed
these performance measures, and the Division submit-ted
them to the Joint Legislative Budget Committee for
approval before any of the HB2003 monies were dis-tributed
to the RBHAs.
1 The Division and RBHAs refer to persons receiving services as consumers. For consistency, that term is used in this report
as well.
State of Arizona
page 4
Northern Arizona Regional Behavioral Health Authority (NARBHA)
The EXCEL Group (Excel)
ValueOptions
Pinal Gila Behavioral Health Association (PGBHA)
Community Partnership of Southern Arizona, Region 5 (CPSA-5)
Community Partnership of Southern Arizona, Region 3 (CPSA-3)
Figure 1: Regional Behavioral Health Authorities
Program Fund Allocations
Through June 30, 2005
Source: Department of Behavioral Health Services' letters to Regional
Behavioral Health Authorities (RBHAs) regarding program
funding, May 2002. The allocation covers the entire life of the
program from fiscal year 2001 through fiscal year 2005.
Excel
$1,446,250
NARBHA
$3,939,152
ValueOptions
$24,740,442
PGBHA
$1,629,015
CPSA-5
$8,231,258
CPSA-3
$1,581,136
As of June 30, 2003, the RBHAs reported that they had expended over $34 million
on HB2003 programs (see Table 2, page 6). The Division requires all the monies to
be spent by January 1, 2005. Reported expenditures for HB2003 programs included
the following:
􀁺􇩈 Housing ($13.6 million)—All five RBHAs reported using HB2003 monies to buy
or build housing for consumers with serious mental illness and to provide sup-port
services to help consumers remain in their homes. One RBHA, Excel, chose
to use almost all its HB2003 monies for housing. As a result of this investment,
the RBHAs were able to obtain an additional $5 million from other sources, such
as the United States Department of Housing and Urban Development and the
State Housing Trust Fund. In addition to buying or building new housing, the pro-gram
provided housing assistance monies to 1,304 consumers as of
September 30, 2003. Finding 1 (see pages 13 through 23) provides additional
information about the housing programs.
􀁺􇩃 Case management teams ($12.0 million)—Four RBHAs reported using HB2003
monies to develop intensive case management teams. According to the
RBHAs’ financial reports, the monies paid for consultants to help develop the
teams, train existing staff, create new positions to staff the teams, and provide
Office of the Auditor General
page 5
Table 1: Performance Measures
for Evaluating Outcomes of
HB2003 Programs for Adults with Serious Mental Illness
Type of Program
Performance Measure1 Housing Case Management Rehabilitation
Reduced hospitalization X X
Reduced symptoms X X
Increased housing stability X
Reduced jail and arrests X X
Increased consumer satisfaction X X X
Increased family satisfaction X X X
Increased safety X
Increased social adjustment X X
Reduced substance abuse X
Increased recovery X
Increased vocational functioning X
Increased vocational participation X
1 See Appendix 1, pages a-iii through a-v for more detailed descriptions of specific measures used.
Source: Auditor General staff analysis of HB2003 Evaluation Plan prepared by the Division of Behavioral
Health Services, August 2001, revised February 6, 2003.
State of Arizona
page 6
Table 2: HB2003 Serious Mental Illness (SMI) Program Allocations and Expenditures
From Program Inception through June 30, 2003
(Unaudited)
CPSA-3 CPSA-5 Excel NARBHA PGBHA ValueOptions Total
Total allocation $1,581,136 $8,231,258 $1,446,250 $3,939,152 $1,629,015 $ 24,740,442 $41,567,253
Expenditures
Housing
Development/capital $1,050,000 $1,314,545 $1,315,713 $1,125,366 $ 965,225 $ 4,858,006 $10,628,855
Operations 267,000 1,926,059 2,193,059
Housing assistance 122,489 703,464 825,953
Rehabilitation and recovery
support services
Other services 444 47,040 48,176 2,962,803 3,058,463
Consumer-run services 550,281 841,898 925,617 2,317,796
Clinical teams
Services 904,535 4,239,879 1,177,698 13,187 4,142,889 10,478,188
Site maintenance and operation 210,000 1,109,978 1,319,978
Training 232,036 232,036
Other expenditures
Transportation—capital 30,000 130,536 57,000 26,087 243,623
Telemedicine 327,314 327,314
Extended evaluation 475,365 475,365
Total program expenditures 1,954,979 6,658,745 1,446,249 3,250,138 1,454,302 17,336,217 32,100,630
Administrative expenditures1 87,445 505,852 297,802 137,734 1,139,454 2,168,287
Total expenditures $2,042,4242 $7,164,597 $1,446,249 $3,547,940 $1,592,036 $18,475,671 $34,268,917
1 Excel used all of its HB2003 allocation for program purposes. It did not use any of the monies for administration.
2 CPSA’s total expenditures include additional nonHB2003 monies. CPSA-3 used $487,136 in nonHB2003 monies, and CPSA-5 used an additional $54,618.
Source: Auditor General staff analysis of Division of Behavioral Health Services’ HB2003 allocation and administrative expenditure schedules and the Regional Behavioral Health Authorities’
recaps of HB2003 programs as of June 30, 2003.
consumer services. Finding 2 (see pages 25 through 34) provides additional
information about the case management programs.
􀁺􇩒 Rehabilitation ($5.4 million)—Three RBHAs reported using HB2003 monies to
develop and pay for rehabilitation services, including psychosocial rehabilitation,
education, and vocational programs. Some of the monies paid for developing
consumer-run services such as clubhouses and drop-in centers, and to hire
consumers for peer counseling and “warm lines.” Finding 3 (see pages 35
through 43) provides additional information about the rehabilitation programs.
􀁺􇩏 Other ($1.0 million)—In addition, the RBHAs reported using the HB2003 monies
in other ways. For example, Excel, NARBHA, and PGBHA bought vehicles for
transporting consumers to services and activities. ValueOptions established an
extended evaluation program to assess people requesting seriously mentally ill
eligibility, but whose diagnosis cannot be determined without extensive treat-ment
and stabilization. Finally, PGBHA purchased and installed telemedicine
equipment at service providers’ locations throughout its region. Telemedicine
involves using videoconferencing equipment to increase access to training, psy-chiatric
services, and case staffing meetings between distant sites.
The RBHAs were allowed to use up to 8 percent of the monies for combined admin-istration
and profit, and as shown in Table 2 (see page 6), four RBHAs have used
some of their allocation for administration, totaling approximately $2.2 million as of
June 30, 2003.
More than 3,300 consumers participated in HB2003 pro-grams
Altogether, 3,358 consumers had participated in one or more of the HB2003 pro-grams
by December 31, 2002. Table 3 (see page 8) shows the consumers’ gender,
age, race, ethnicity, and diagnosis as reported in their enrollment and assessment
data. In addition to these 3,358 program participants, ValueOptions had enrolled
another 242 consumers in its extended evaluation program.
The HB2003 program participants represented approximately 13 percent of the near-ly
26,000 adults with serious mental illness who were enrolled in the behavioral health
system as of December 31, 2002. In its plan specifications, the Division directed the
RBHAs to select consumers with four specified types of major mental illness to par-ticipate
in the HB2003 programs: schizophrenia, delusional disorders, affective psy-choses
such as bipolar disorder, and other psychoses. According to the Division’s
former medical director, sufficient research exists on these illnesses to make them
more predictable than serious mental illness in general. Some RBHAs added further
Office of the Auditor General
page 7
State of Arizona
page 8
Table 3: Number of HB2003 Consumers with a Serious Mental Illness Served
As of December 31, 2002
CPSA-3
CPSA-5
Excel
NARBHA
PGBHA
ValueOptions
Total
Percentage
Total number
44
188
63
128
111
2,824
3,358
100.0
Demographic categories
Gender
Female 14 88 34 69 63 1,475 1,743 51.9
Male 30 100 29 59 48 1,349 1,615 48.1
Age Groups
18-25 5 28 9 4 166 212 6.3
26-35 5 33 14 10 22 485 569 17.0
36-45 13 57 14 38 34 890 1,046 31.1
46-55 15 53 20 51 31 801 971 29.0
56-65 5 14 6 23 16 347 411 12.2
66 and over 1 3 6 4 135 149 4.4
Race
White 44 167 44 114 100 2,001 2,470 73.5
Black/African-American 12 4 4 9 564 593 17.7
Asian 1 2 93 96 2.9
Native-American 5 5 1 32 43 1.3
Other/unknown 4 9 9 134 156 4.6
Ethnicity
Hispanic1 4 14 14 10 15 373 430 12.8
Non-Hispanic 40 174 49 118 96 2,451 2,928 87.2
Diagnosed with a serious mental illness
Delusional disorder 2 3 9 14 0.4
Major depressive disorder 18 92 30 64 51 1,091 1,346 40.1
Schizophrenia 19 70 28 44 40 1,126 1,327 39.5
Other psychotic disorder 3 10 1 7 9 199 229 6.8
Other/unknown 2 13 4 13 11 399 442 13.2
CPSA-3—Community Partnership of Southern Arizona—Cochise, Graham, Greenlee, and Santa Cruz Counties
CPSA-5—Community Partnership of Southern Arizona—Pima County
NARBHA—Northern Arizona Regional Behavioral Health Authority
PGBHA—Pinal Gila Behavioral Health Association
1 A Hispanic individual can be any race.
Source: Auditor General staff analysis of enrollment and assessment data provided by the Division of Behavioral Health Services and its Regional Behavioral Health Authorities, including all
consumers enrolled from program inception through December 31, 2002.
selection criteria in their proposals for using the HB2003 money. For example,
NARBHA planned to focus on individuals identified as high utilizers of their services,
ValueOptions targeted its plan to the Arnold v. Sarn priority population, and PGBHA
planned to target its case management to consumers with the greatest need.
The impact of HB2003 will extend beyond this group of participating consumers. For
example, the housing purchased using HB2003 monies will continue to be used for
persons with serious mental illness for at least 15 years under use restrictions on the
properties. In addition, the RBHAs plan to continue other programs that were sup-ported
with HB2003 monies, such as the consumer-run drop-in centers and club-houses.
According to division officials, they plan to conduct an evaluation of the programs
that the RBHAs developed with their HB2003 monies once the RBHAs have spent all
the monies. Similar to this audit, the Division plans to assess the RBHAs’ programs
in accordance with the performance measures that the Joint Legislative Budget
Committee (JLBC) approved.
Scope and methodology
As required by legislation, this audit report focused on the Division’s ability to meet
the performance measures it established for its three major programs (see Table 1,
page 5, and Appendix 1, page a-iii through a-v), and contains findings in all three
areas:
􀁺􇩆 First, consumers benefited from the housing programs, but the Division should
conduct its own impact analysis since consumers at only three RBHAs had lived
in the housing long enough to be included in the audit analysis.
􀁺􇩓 Second, consumers benefited from the intensive case management programs,
but the Division should conduct its own analysis on arrests since only two of four
RBHAs had complete enough information to include in the Auditor General’s
analysis, and also look at length of hospital stay. In addition, it should determine
the causes for the lack of results at one RBHA.
􀁺􇩔 Third, consumers increased their participation in rehabilitation activities, particu-larly
at two RBHAs, but the Division should conduct its own analysis to deter-mine
whether other consumers eventually increase activity levels.
A combination of the following methods was used in the audit:
􀁺􇩁 Auditors conducted two main types of analysis to examine the outcomes of the
HB2003 programs. To conduct both parts of the outcome analysis, auditors
Office of the Auditor General
page 9
obtained and verified records from the Division’s enrollment, assessment, and
encounter (services provided) databases for the period July 1, 2000 through
December 31, 2002 (enrollment data), or January 31, 2003 (assessment and
encounters). The first type of analysis compared consumer symptoms and func-tioning
levels, housing independence status, participation in vocational and
rehabilitation activities, arrests, and hospitalizations before and after program
participation. The second type of analysis compared program participants’
symptoms and other performance measures with those of similar consumers
who did not participate in the programs.
Appendix 2 (see page a-ix) provides detailed results of the outcome analysis.
􀁺􇩔 To understand the results of the outcome analysis and put them in context, audi-tors
reviewed division program specifications, RBHA spending plans, pertinent
literature regarding each program (see Bibliography, pages a-xli through a-xvii),
criteria that the Division established for each program, and RBHA reports show-ing
whether their programs matched the Division’s criteria. Auditors also exam-ined
documents related to the Arnold lawsuit regarding persons with serious
mental illness and interviewed representatives of the plaintiffs’ attorneys and the
court monitor’s office.
􀁺􇩔 To assess the housing programs that received HB2003 monies, auditors toured
16 housing sites, interviewed RBHA and service provider staff, and interviewed
14 consumers living at the sites. To determine whether the Division used sound
procedures for selecting housing and ensuring its continued use for persons
with serious mental illness, auditors interviewed Arizona Department of Housing
officials and examined documents showing their review and approval of division
proposals, reviewed purchase documents showing the terms and conditions for
use of purchased or constructed housing, reviewed consumer leases, and
reviewed division expenditure reports and documents showing how the RBHAs
and service providers used HB2003 monies as matching funds to obtain hous-ing
money from other sources.
􀁺􇩔 To assess the case management programs that received HB2003 monies, audi-tors
met with 19 members of the new case management teams, interviewed 8
consumers, surveyed 10 service providers, examined training plans and related
materials, and reviewed a letter and other documents illustrating individual con-sumers’
experiences with the case management teams. Auditors also examined
reports of successful intensive case management programs in other areas of
the country, including the Madison, Wisconsin, Program of Assertive Community
Treatment, which first developed and tested the principles of intensive case
management.
􀁺􇩔 To assess the rehabilitation programs that received HB2003 monies, auditors
toured two consumer-run programs, including one consumer recovery support
State of Arizona
page 10
center in Prescott and one clubhouse in Pima County; and conducted site visits
at two ValueOptions HB2003 clinical sites and three non-HB2003 ValueOptions
clinics. Auditors also interviewed four NARBHA, two CPSA, and ten
ValueOptions consumers; interviewed nine ValueOptions’ rehabilitation special-ists;
reviewed a videorecording of consumer and staff speeches at a peer sup-port
training graduation ceremony; and reviewed a consultant’s report regard-ing
rehabilitation services in Southern Arizona. In addition, auditors interviewed
officials and six vocational counselors at the Department of Economic Security
Rehabilitation Services Administration (RSA) and examined the Interagency
Service Agreement between RSA and the Division of Behavioral Health Services
that explains each agency’s responsibilities.
This audit was conducted in accordance with government auditing standards.
The Auditor General and staff express appreciation to the director of the Department
of Health Services, and management and staff of the Division of Behavioral Health
Services and its Regional Behavioral Health Authorities for their cooperation and
assistance throughout the audit.
Office of the Auditor General
page 11
State of Arizona
page 12
Consumers benefited from housing programs
According to their quarterly reports to the Division, the RBHAs used $13.6 million in
HB2003 monies, or approximately 40 percent of the total spent as of June 30, 2003,
to develop housing and related programs. RBHAs developed 334 new housing
spaces, which was an increase of about one-fourth over the roughly 1,250 spaces
previously available. The impact of the housing program varied by RBHA and by con-sumers’
level of functioning. In general, consumers with more severe levels of dys-function
showed the greatest improvement from living in the new housing.
Consumers with slight levels of dysfunction showed little or no change. However,
since two RBHAs’ new-housing consumers had not lived in their homes long enough
to be included in this audit’s analysis, the Division should conduct its own analysis of
the housing program’s impact and provide technical assistance to the RBHAs based
on the results of its research.
Housing important for consumers with serious mental
illness
According to research, stable housing is an important factor in a consumer’s recov-ery
from mental illness. Consumers without stable housing focus on meeting their
basic needs, and cannot focus sufficiently on their recovery. However, people with a
serious mental illness commonly cannot attain suitable housing, and even lose their
homes and become homeless. For example, issues such as criminal records and
substance abuse can disqualify people as renters or borrowers, and increase their
likelihood of becoming homeless. According to a housing plan written by two state
agencies, Arizona also has a shortage of affordable housing for lower-income peo-ple,
which includes many individuals with serious mental illness. This plan suggests
that 17,000 low-income Arizonans with severe and persistent mental illness are at risk
of becoming homeless.1 Additionally, the Division estimates that there are at least
Stable housing is an
important factor in
recovery from mental ill-ness.
1 Department of Commerce, Department of Economic Security, FY 2000-2004 State of Arizona Consolidated Plan.
Office of the Auditor General
FINDING 1
page 13
1,500 individuals with a serious mental illness who are homeless in Maricopa County,
and another 750 individuals who lack adequate and/or safe housing.
Research shows that people with a serious mental illness need housing that is coor-dinated
with other support services. For example, one national expert reports that
people with a serious mental illness need access to an array of residential options
offering varying levels of supervision, coordinated with other recovery support serv-ices,
to achieve the highest level of self-sufficiency. A recent study at the University of
Arizona compared outcomes for persons in housing that provides daily on-site treat-ment
services with persons in independent housing. The study looked at various out-comes
including hospitalization, use of emergency rooms or crisis services, and time
served in jail, and found that residents in both types of housing fared about the same.
However, those in the independent housing had longer stays in their original place-ment
and were less likely to experience an episode of homelessness.
Further, consumers should have some say in the decision to live in either supervised
or independent housing. In one study, consumers who were given a choice among
housing options reported greater housing satisfaction, improved housing stability,
and greater psychological well-being. Another study found that lack of consumer
choice can actually accelerate homelessness because consumers may choose the
relative independence of the streets to the restrictions of a highly structured residen-tial
facility. One theory to explain this phenomenon is that choice provides opportuni-ties
for people with serious mental illness to experience a sense of control over life
events.
Decisions in two lawsuits confirm the State’s responsibility for providing community
housing to persons with serious mental illness. First, the 1996 Maricopa County
Superior Court-approved exit agreement for the Arnold v. Sarn lawsuit requires the
Division to provide an array of flexible community housing options for people with
serious mental illness, and the 1998 supplemental agreement required the Division
State of Arizona
page 14
Case Example
J.O. has been in the mental health system for more than 20 years and had been separated
from her family for years. During the past year, J.O. had various psychiatric relapses. Her
symptoms included delusions and hallucinations, including a fear that she was being poi-soned,
resulting in her discontinuing her medications. The clinical team worked on trying
to build enough trust to allow for referral to multiple programs that could help her. J.O. was
placed in HB2003 housing, and received home and self-management skills training. She
stabilized on her medications, participated in activities outside her home, and performed
her daily activities with greater skill. She had not experienced a psychiatric relapse in 8
months as of August 2003. She left her HB2003 housing only because her physical health
has deteriorated and required a higher level of nursing care.
to develop a housing strategic plan.1 Similarly, the 1999 U.S. Supreme Court deci-sion
in Olmstead v. L.C. prohibits keeping disabled persons in institutions unneces-sarily
and requires states to provide community-based placements to persons who
might otherwise be institutionalized.2
Housing and housing support
provided
To support the goals of HB2003, the RBHAs
reported that they spent more than $13.6 million
developing a number of housing programs to
increase participants’ self-sufficiency either by
providing more independent housing or helping
them maintain existing housing.
HB2003 monies used to acquire variety
of housing—The RBHAs and their subcon-tracted
service providers reported using approxi-mately
$10.6 million of the HB2003 monies to buy
or build houses and apartments at 39 sites in 21
cities around the State. The new housing pro-vides
334 additional beds, an increase of about
one-fourth over the Division’s approximately
1,250 previously available beds as reported by
the Division and its RBHAs.3 Figure 2 shows the
general locations of the new housing, and
Appendix 3 (see page a-xli through a-xliii) pro-vides
detailed information about the locations,
types, costs, opening dates, and housing occu-pancy.
Altogether, the RBHAs had placed 272 HB2003
consumers in the new housing by September 30,
2003 (see Table 4, page 16). In addition, 96 other
tenants were placed in HB2003 housing, includ-ing
children of the HB2003 consumers and other
persons with serious mental illness not designat-ed
as HB2003 participants. The first tenant
1 160 Ariz. 593; 775 P.2d 521; 1989, Maricopa County C-432355.
2 Olmstead v. L.C., 119 S. Ct. 2176 (June 22, 1999).
3 The number of beds previously available is an approximation because persons with serious mental illness may qualify
for other low-income housing such as U.S. Department of Housing and Urban Development (HUD) program housing. In
addition, some available beds are occupied by family members of persons with serious mental illness.
Office of the Auditor General
page 15
Northern Arizona Regional Behavioral Health Authority (NARBHA)
The EXCEL Group (Excel)
ValueOptions
Pinal Gila Behavioral Health Association (PGBHA)
Community Partnership of Southern Arizona, Region 5 (CPSA-5)
Community Partnership of Southern Arizona, Region 3 (CPSA-3)
Excel
NARBHA
ValueOptions
PGBHA
CPSA-5
CPSA-3
Figure 2: House Bill 2003 Housing Locations by Regional
Behavioral Health Authorities
As of June 30, 2003
Source: Auditor General staff analysis of data provided by the Arizona Department
of Housing and the Regional Behavioral Health Authorities.
moved into an Excel apartment complex in
Yuma on February 5, 2001, but most projects
did not open until 2002 or 2003. (See Appendix
3, pages a-xli through a-xliii.)
Generally, the new housing falls into two broad
categories:
􀁺􇩓 Supervised Housing (93 beds)—Two
RBHAs—NARBHA and ValueOptions—devel-oped
supervised housing, which is designed to
be individualized and integrated into the com-munity,
in the most typical and least-restrictive
setting possible. The consumer’s supervisory
needs can range from individuals who can man-age
noncrisis issues for 1 or 2 days until a
scheduled staff visit, to individuals who require
substantial support and skill training in a struc-tured
environment. These 15 new houses and
apartments can house a maximum of 93 indi-viduals.
􀁺􇩉 Independent Living (241 beds)—All five RBHAs developed independent liv-ing
options, which include both apartments and single-family houses. These
are settings where an individual can live without on-site supervision from
mental health staff. The 24 new HB2003 sites can house a maximum of 241
individuals.
Since self-sufficiency is the HB2003 program’s goal, consumers must pay rent to
live in the new housing. Generally, monthly rent is 30 percent of the consumer’s
monthly income. This amount matches federal guidelines for affordable low-income
housing. These monies are used to maintain the housing. Consumers in
some independent living sites can bring their families to live with them, just as
they would if they were renting on their own. In addition, consumers sign a lease
and must abide by its terms and restrictions. Consumers can remain in the hous-ing
as long as they choose, unless they violate the terms of the lease. Tenure in
housing is an important aspect of housing stability.
Other programs support consumers in community housing—
Two RBHAs—ValueOptions and PGBHA—used part of their HB2003 monies for
other housing-related services. They had served 1,304 consumers through these
other housing-related programs by September 30, 2003 (see Table 4).
ValueOptions allotted approximately $3.8 million for an in-home housing assis-tance
program that provides training and assistance in daily living skills such as
meal preparation, housekeeping, budgeting, and social and recreational activi-
State of Arizona
page 16
Table 4: Number of HB2003 Housing Consumers by RBHA
February 1, 2001 through September 30, 2003
Number of
Consumers in
HB2003
Housing
Number of
Consumers
Receiving Housing
Assistance Monies1
Total
Number of
Housing
Consumers
CPSA-5 35 35
Excel 77 77
NARBHA 11 11
PGBHA 22 115 137
ValueOptions 127 1,189 1,316
Total 272 1,304 1,576
1 Column includes housing assistance, move-in assistance, and community tenure support
programs.
Source: Auditor General staff analysis of RBHA program enrollment rosters for the period
February 1, 2001 through September 30, 2003.
ValueOptions house providing 24-hour supervised living.
Excel apartment complex providing independent living.
ties to most of its HB2003 housing participants. In addition, ValueOptions and
PGBHA set aside some funding to help consumers remain in existing community
housing or make the transition from homelessness to housing. Specifically,
ValueOptions allotted $500,000 for a move-in assistance program to help consumers
pay expenses such as security and utility deposits. ValueOptions also allocated
$210,000 for a community tenure program that helps consumers keep their homes
by paying rent or utilities if they get behind in their payments. Both programs have a
dollar limit from $1,000-$1,500 per consumer and are one-time-only. PGBHA spent
about $122,500 on its housing assistance program.
Consumers benefit from housing programs
Consumers at ValueOptions and Excel benefited from the HB2003 housing.1 These
consumers showed greater improvements in a variety of performance measures
than did two comparison groups. (See Appendix 2, page a-ix through a-xiv, for more
details on the comparison groups.) When controlling for functioning level, Value
Options showed effects for all functioning levels, while Excel showed effects for more
moderately functioning consumers. Excel’s higher-functioning consumers showed
deterioration in their functioning levels. However, consumers in both RBHAs general-ly
either maintained or increased their level of independence.
Continued analysis of the HB2003 housing’s impact is needed. Auditors’ analysis
was performed with limited data from ValueOptions, Excel, and CPSA-5 consumers.2
Consumers in the other two RBHAs generally had not moved into the new housing
early enough to be included in this analysis. Further, some outcomes, such as hos-pitalizations
and arrests, occurred so rarely among consumers that auditors were
prevented from drawing meaningful conclusions.
Consumers’ functioning improved in new housing—Consumers who
lived in the new housing for at least 6 months made greater gains on a variety of per-formance
measures than consumers on a waiting list for the new housing. Several
performance measures were identified for evaluating the outcomes of the housing
program, and HB2003 consumers showed more improvement than their counter-parts
in two comparison groups on most measures, as shown in Table 5 (see page
18). Gains for consumers in the new housing occurred on all six examined dimen-sions
of the Arizona Level of Functioning Assessment (ALFA), with the strongest and
most consistent gains in the family and living environment dimension, as shown in
Table 8 (see Appendix 2, page a-xv).
As shown in Table 9 (see Appendix 2, page a-xvi), when results are analyzed by
RBHA, only ValueOptions consumers had statistically significant gains in most meas-
1 The evaluation time frame spanned approximately 24 months, from the first time a consumer moved into HB2003 hous-ing
in February 2001 through January 31, 2003.
2 The number of consumers at CPSA-5 was too small to make meaningful comparisons across RBHAs. However, the
CPSA-5 consumers are included in state-wide results.
Office of the Auditor General
page 17
State of Arizona
page 18
Table 5: Housing
Progress of HB2003 Housing Consumers
and Two Comparison Groups
by Performance Measure1
July 1, 2000 through January 31, 2003
Consumers in HB2003
Housing Compared To
ValueOptions
Consumers ValueOptions
Performance Measure in Non-HB2003 Homeless
and Expected Outcome Housing Consumers
Arizona Level of Functioning Assessment (ALFA)
Family, living environment (increased safety) 􀁺􇨠 􀁺􇨠
Feeling, affect, mood (reduced symptoms) 􀁼􇰠 􀂀􈀠
Interpersonal relations (increased social adjustment) 􀂀􈀠 􀁼􇰠
Self-care (increased self-sufficiency)2 􀂀􈀠 􀂀􈀠
Substance abuse (reduced substance abuse) 􀂀􈀠 􀁼􇰠
Thinking and cognition (reduced symptoms) 􀁼􇰠 􀂀􈀠
Clinical Global Impression (CGI)
Global improvement (reduced symptoms)2 􀁼􇰠 􀁼􇰠
Severity of symptoms (reduced symptoms)2 􀁼􇰠 􀁼􇰠
Housing independence (increased self-sufficiency)2 NA NA
Hospitalization (reduced hospitalizations)
Rate of admissions NA NA
Length of stay NA NA
Arrests (reduced arrests) NA NA
Symbol key:1
􀁺􇨠 Improved much more than comparison group
􀂀􈀠 Improved more than comparison group
􀁼􇰠 No difference between groups
􀂵􋔠 Worsened more than comparison group
NA not available
1 See Appendix 2, Tables 10 and 11 (pages a-xvii and a-xviii), for detailed results on each measure.
Differences greater than 10 percent of the total available points on the measure (5 out of 50 for
ALFA; 0.7 out of 7 for CGI) are shown as improved much more than comparison groups.
Differences that were not statistically significant are shown as no difference between groups.
2 Not a performance measure identified by the Division and the RBHAs for housing.
Source: Auditor General staff analysis of assessment data provided by BHS and the RBHAs for the
period of July 1, 2000 through January 31, 2003.
ures of symptom severity. At Excel, consumers made gains only on the substance
abuse dimension of the ALFA. Both ValueOptions and Excel included substance
abuse prohibitions in the lease requirements for the new housing, which may help to
explain the improvement on that measure at both RBHAs.
At ValueOptions, consumers with the most severe dysfunction before being placed
in their housing showed the most dramatic gains, as shown in Table 9 (see Appendix
2, page a-xvi). On average, these consumers gained enough to move them to the
moderate dysfunction range. Consumers in the comparison groups who started with
the severest dysfunction also made gains (see Table 10, Appendix 2, page a-xvii),
suggesting there may be a natural tendency for the most severe consumers to show
improvement, but their gains were smaller than those for the consumers in the
HB2003 housing. Consumers in the moderate functioning range at ValueOptions
also made modest gains, and those consumers with slight dysfunction stayed sta-ble.
At Excel, consumers in the more moderate ranges made significant gains while those
classified as having only slight dysfunction remained relatively stable. There was no
statistically significant change for the most severely impaired consumers at Excel, but
the number of consumers in this category was relatively small.
Another scale measuring symptom severity, the Clinical Global Impression (CGI),
showed mixed results for HB2003 consumers. The CGI measures the effects of psy-chotropic
medications, and is completed by the clinician who monitors consumer
medications. It includes assessments of symptom severity and improvement in their
condition, and is a commonly used measure of global functioning. The differences
between HB2003 consumers and the waiting list group consumers were not statisti-cally
significant, suggesting that there is no difference between HB2003 consumers
and the comparison group consumers on these two scores when all three RBHAs’
consumers are combined. However, ValueOptions’ consumers improved on severity
and stayed the same on improvement, while Excel’s consumers stayed the same on
severity and got worse on improvement. Results for the CGI are shown in Tables 11
and 12 (see Appendix 2, pages a-xviii and a-xix).
Consumers in new housing are independent—The final measure exam-ined
for consumers in both RBHAs’ new housing showed that their level of inde-pendence
remained the same or improved after entering the HB2003 program.
About one-third of the consumers moved into more independent housing, and about
two-thirds remained at the same level of independence. Most of the consumers at
Excel started and stayed at a very high level of independence. At ValueOptions, most
consumers started at a lower level of independence and moved to a higher level,
while those who started at the highest level of independence remained at that level.
Consumers satisfied with new housing—Auditors interviewed 14 consumers
living in the new housing. Most reported satisfaction with their new housing situation,
Office of the Auditor General
page 19
although two said they would prefer to live in other situations. For example, a
ValueOptions consumer who lives in a four-bedroom house with three other men said
he would like to be on his own, although he likes living in the house. However, a court
order required him to move into a supervised setting when he left the Arizona State
Hospital. One consumer told auditors he is very happy in his Excel apartment, where
he has more responsibility and more freedom than he had in previous placements.
He said he is learning living skills and has friends at the apartment complex, and
wants to stay there. Another consumer at the same complex said he had been home-less
for many years, and had felt a lot of stress in previous residential placements,
but now he is comfortable and gets a good night’s sleep. A consumer in a transitional
facility in Yuma told auditors she had been living in her van for about 2 years, and she
feels much better and suffers less from panic, anxiety, and depression.
Differences in consumers and programs may help to explain differ-ent
results—Excel and ValueOptions served different consumers and accordingly
designed their new housing programs differently, with Excel providing more inde-pendent
living and ValueOptions providing more 24-hour supervised settings, as
shown in Appendix 3 (see pages a-xxxix through a-xliii). The differences in programs
and consumers may help characterize Excel’s gains in comparison to ValueOptions’,
even though, on average, the Excel consumer had lived in the new housing longer.
In general, consumers with the most severe dysfunction made the greatest gains, but
Excel’s consumers are not proportionately as severe in dysfunction as ValueOptions’.
Therefore, they may have been less likely to make large gains. Most of Excel’s con-sumers
were in the slight-to-moderate dysfunction range prior to move-in, while most
ValueOptions’ consumers were in the moderate or severe range. As shown in Table
9 (see Appendix 2, page a-xvi), Excel’s gains are limited to the moderately function-ing
group.
In addition, most of Excel’s consumers live in housing that affords them greater inde-pendence
than ValueOptions’ consumers, and while still integrated with services,
offers fewer in-home services. Most ValueOptions consumers received services from
an in-home program that trains and assists consumers in daily living activities.
Further, most ValueOptions’ sites are supervised housing. Excel by contrast relied
more on independent housing, offering the same services to HB2003 consumers as
to other consumers, though with more focus on in-home assistance. Although a
recent University of Arizona study found independent housing yields similar gains to
housing with more supervision, and Excel and ValueOptions were comparable for
those consumers with moderate dysfunction, Excel’s consumers with slight dys-function
showed a deterioration in the interpersonal relations dimension of the ALFA
(see Table 9, page a-xvi).
Continued analysis important—Consumers in three RBHAs—CPSA, NARBHA,
and PGBHA—generally had not moved into HB2003 housing early enough to be
included in this audit’s analysis. In addition, hospitalizations and arrests are rare
State of Arizona
page 20
Consumers report satis-faction
with their new
housing.
among the consumers in the new housing, so auditors had insufficient data to draw
conclusions about those two performance measures. The Division should conduct
additional analysis to follow up on the results of the Auditor General’s analysis and
draw additional conclusions about the impact of HB2003 housing programs and
services. Specifically, because auditors found differences in the impact of the new
housing between the RBHAs included in this analysis, the Division should analyze
performance indicator data regarding the other three RBHAs when their consumers
have lived in the new housing at least 6 months. In addition, the Division should ana-lyze
the program’s impact on hospitalization and arrests for consumers at all the
RBHAs that invested in housing once sufficient data is available. Finally, the Division
should work with Excel to determine what outcomes should be expected for con-sumers
in Excel’s independent housing and analyze the impact of Excel’s program
against those expected outcomes. The Division could conduct these analyses as
part of the evaluation it plans to conduct once the RBHAs have spent all their HB2003
monies. Based on analysis results, the Division should develop any needed recom-mendations
and provide technical assistance to improve the RBHAs’ housing pro-grams
for persons with serious mental illness.
Programs appear well-designed and help address hous-ing
gap
Although the programs’ impacts on consumer functioning and symptom severity
were modest, the planning and oversight mechanisms that the Division put in place
prior to approving the RBHAs’ various HB2003 housing projects appear to be appro-priate.
For example, the Division worked with the RBHAs to establish housing pro-gram
guidelines based on a national housing model for persons with serious mental
illness and reviewed the RBHA projects according to these standards. The Division
also involved the Arizona Department of Housing (Housing) in its decisions regard-ing
property acquisition because of its experience in developing public housing. The
projects have also helped the Division address legal requirements set forth in the
Arnold v. Sarn litigation and meet goals that it set forth in the court-approved housing
strategic plan.
Division monitors programs’ adherence to standards—The Division and
the RBHAs developed housing program measures based on a national model for
housing programs. Every 6 months, each RBHA must assess each housing project
according to the measures and report to the Division on each site’s fidelity to the
model. The report scores each program on five areas: choice of living arrangements,
separation of housing and service staff, residents’ rights of tenancy consistent with
landlord/tenant law, residents’ choice of accepting behavioral health services, and
social/recreational activities. According to division officials, all the open housing sites
inspected through July 17, 2003, currently meet these standards.
The Division involved
the Arizona Department
of Housing in its deci-sions
regarding property
acquisition.
Office of the Auditor General
page 21
Department of Housing helps acquire and protect assets—Prior to
using any HB2003 monies to acquire housing, the Division entered into an intera-gency
agreement with the Arizona Department of Housing for technical assistance.
The Division paid Housing $228,000 for its services. Specifically, Housing helped
each RBHA identify its goals and obtain HB2003 properties. Housing provided an
application package, which the RBHA and/or service provider filled out prior to mak-ing
any purchase. Housing staff reviewed the application and toured each prospec-tive
site, considering issues such as location, price, and condition of the structure
prior to approving the application. After housing officials approved the application,
they forwarded it to the Division for review. The Division considered other issues, such
as sustainability, before approving the application and releasing monies for the pur-chase.
In addition to assisting with the purchasing process, Housing also helped some
RBHAs use their HB2003 funds as a match to obtain monies from other sources,
such as the United States Department of Housing and Urban Development’s
Supportive Housing Programs, and the State Housing Trust Fund. Altogether, the
RBHAs obtained an additional $5 million from these sources and were able to pur-chase
more housing for individuals with serious mental illness.
Finally, to protect the State’s investment, Housing worked with the Attorney General’s
Office to develop use restrictions specifically for the HB2003 housing. These 15-year
use restrictions require the projects to be used exclusively for housing adults with
serious mental illness. If the RBHA or its subcontractor does not conform to the
restrictions, the State can take possession of the property by declaring the agency in
default of the contract. While the restrictions are in place, Housing will inspect the
housing sites annually. After 15 years, the State lifts the restrictions, and the RBHAs
or service provider agencies will own the properties outright.
The Division and its RBHAs should continue to work with Housing to find funding for
additional housing projects in Maricopa County and the rest of the State, as long as
the Division’s analysis results indicate the programs are having an impact. Those
funds could then be matched to other federal or state funds, similar to the methods
used on several HB2003 housing projects.
Housing helps address Arnold v. Sarn agreement—Finally, the housing
also helped the State address the terms of the Arnold v. Sarn exit agreement and the
housing strategic plan required by the agreement. For example, the agreement
required the Department to provide 300 community living arrangements for individu-als
living in supervisory care homes and/or board and care homes. Most of
ValueOptions’ 109 beds were targeted to serve the priority populations identified in
this exit agreement, such as those identified above. Likewise, the housing strategic
plan proposed developing a plan to fill housing gaps for people with serious mental
illness. The Division and ValueOptions report using HB2003 funding to partially fill the
identified housing gaps. However, despite the addition of HB2003 housing, the
RBHAs used HB2003
monies to obtain addi-tional
financial support.
State of Arizona
page 22
The average cost of each
new bed in the program is
$3,314 per year for 15
years.
Division estimates that more than 2,000 people in Maricopa County, as well as peo-ple
in other urban and rural regions, still need housing.
Recommendations
1. The Division should conduct its own impact analysis of HB2003 housing pro-grams
and services. Specifically, the Division should:
a. Assess consumers’ progress at CPSA, NARBHA, and PGBHA after their
consumers have lived in the new housing for at least 6 months.
b. Determine the HB2003 housing programs’ impact on hospitalization and
arrests once sufficient data becomes available.
c. Work with Excel to determine what outcomes should be expected for con-sumers
in Excel’s independent housing, and analyze the impact of Excel’s
housing program against those expected outcomes.
The Division could conduct the analyses identified above as part of the HB2003
program evaluation it plans to conduct once the RBHAs have expended all of
their HB2003 monies.
2. The Division should develop recommendations and provide technical assis-tance
to the RBHAs to improve consumer housing based on the results of its
research.
Office of the Auditor General
page 23
State of Arizona
page 24
Consumers show modest gain from
intensive case management programs
The RBHAs used $12 million of HB2003 monies, or 35 percent of total spending as
of June 30, 2003, to develop intensive case management teams. These teams pro-vide
a range of case management and other services, often at the consumer’s home
or in other community settings. HB2003 consumers made modest improvements in
symptoms, while a comparison group stayed the same or worsened. Further, among
those consumers with the most severe symptoms, greater gains are apparent. Only
one RBHA, PGBHA, did not show expected gains. The RBHAs plan to carry the pro-grams
forward using different funding and create new programs based on the
HB2003 model. These plans to continue the case management model developed
with HB2003 monies increase the importance of the Division’s and RBHAs’ follow-up
evaluations.
Intensive case management teams developed
To support HB2003 goals of supporting recovery and helping people with serious
mental illness achieve the highest level of self-sufficiency, four RBHAs established
new intensive case management teams.1 Intensive case management teams pro-vide
a range of services, including substance abuse and vocational counseling,
medication management, and life-skills training. These teams differ from traditional
case management in their staffing structure, caseload size, and frequency of contact.
In addition, team members provide many services directly instead of coordinating all
services through other providers, as in traditional case management. Several
research studies on Assertive Community Treatment (ACT), a form of intensive case
management, have linked this approach with decreased symptom severity, fewer
hospitalizations, and increased life satisfaction. The RBHAs report using $12 million
in HB2003 monies to pay for training and consultation to establish the teams, team
member and other staff positions, and services provided by the teams.
Four RBHAs established
new intensive case
management teams.
1 CPSA, NARBHA, PGBHA, and ValueOptions established these teams. CPSA developed teams in both its geographic
service areas. The fifth RBHA, Excel, reports that it used all its HB2003 monies for its housing program and transporta-tion.
Office of the Auditor General
FINDING 2
page 25
The RBHAs developed two main types of teams:
􀁺􇩈 High-intensity case management teams—All four RBHAs developed teams that
deliver high-intensity case management, often in community settings such as
the consumer’s neighborhood or at an employment site. The RBHAs and their
providers established a variety of teams that incorporate some, though not all,
features of the ACT model. Each RBHA uses teams of behavioral healthcare
professionals and technicians such as housing, rehabilitation, or vocational,
substance abuse, and living skills specialists to provide highly individualized,
direct services. For example, Superstition Mountain Mental Health Center, a
PGBHA provider, has a high-intensity case management team that includes a
living skills specialist who teaches cooking and nutrition classes and other skills
that allow consumers with disabilities to live more independently. At one CPSA
provider, the high-intensity case management team includes a registered nurse
with substance abuse treatment experience. Team services are available to
some providers’ consumers 7 days a week, 24 hours a day, while other
providers rely on their existing crisis system for after-hours services. Low case-loads—
as few as 60 consumers per case management team at ValueOptions
and PGBHA, or 12 consumers per staff member—enable the teams to provide
this intensive level of service. In contrast, service providers stated that normal
caseloads can range from 35 to 100 consumers per staff member. According to
the Division, staffing levels and the degree of community-based services vary
according to each RBHA’s resources and geography.
􀁺􇩓 Supportive treatment teams—ValueOptions developed this less-intensive pro-gram
for consumers who have achieved higher levels of functioning and require
less-intensive levels of case management. Supportive treatment teams focus on
maximizing community resources and coordinating care for the consumer.
Providers and state agencies are much more involved in the care of these con-sumers,
and a lesser emphasis is placed on direct services from the team. Still,
consumers receive services such as substance abuse and vocational counsel-ing,
consumer advocacy, and individual therapy through these teams. Because
services are less intensive than high-intensity case management, staff-to-con-
Supportive treatment
teams have served the
highest number of
HB2003 consumers.
State of Arizona
page 26
Case Example
B.W., a 42-year-old ValueOptions consumer, had been in the care of his parents his entire
adult life and required a great deal of support to get through a typical day. Since 1990, he
was in and out of the behavioral health system four times. He almost constantly heard voic-es,
and he was delusional and irritable. He experienced difficulty attending to personal
hygiene and was virtually unable to live independently. However, after a year of high-inten-sity
case management, B.W. has been free from symptoms for several months, voluntarily
takes his medication, lives semi-independently, and would like to return to work.
sumer ratios are targeted at 1:30. Supportive treatment teams account for 77
percent of all consumers enrolled in HB2003 programs. According to
ValueOptions financial reports dated June 30, 2003, ValueOptions had expend-ed
approximately $1.3 million for supportive treatment teams as of June 30,
2003, compared to $3.2 million for its high-intensity case management teams.
As shown in Table 6, 2,221 consumers, or about 8.5 percent of the adults with seri-ous
mental illness in the behavioral health system, had participated in these pro-grams
as of December 31, 2002. However, not all
had participated in the programs for at least 6
months and had complete assessment data,
so only 1,548 (70 percent) are included in the
analysis reported in this finding.
The RBHAs report using HB2003 monies to pay
for training and consultation in preparation for
setting up the teams, as well as to pay for staff
positions and consumer services. For example,
NARBHA contracted with the South Carolina
Center for Innovation in Public Mental Health for
training and consulting services on a high-inten-sity
case management model for rural areas.
Both PGBHA and ValueOptions contracted with
experts to provide training on intensive case
management. In addition, three of the RBHAs used HB2003 monies to pay for inten-sive
case management team member positions. According to the RBHAs and
providers, team members provide direct services such as substance abuse and
vocational counseling, daily living skills training, and medication management.
New case management programs benefit consumers
Consumers treated by the new intensive case management teams made modest
improvements in their symptoms overall, but consumers with more severe dysfunc-tion
prior to entering the new program showed more marked gains.1 The Division and
the RBHAs identified several performance measures for evaluating the outcomes of
the intensive case management programs, as shown in Table 7 (see page 28).
Consumers who participated in the new programs, in contrast to a comparison
group, showed progress on most measures of functioning as a result of the intensive
case management they received. However, one RBHA’s consumers did not show
the same success as the other RBHAs’ consumers; therefore, the Division should
examine the causes for this RBHA’s lack of significant results.
1 The evaluation time frame spanned approximately 24 months from the time of earliest enrollment in February 2001
through January 31, 2003.
Office of the Auditor General
page 27
Table 6: Consumers Served by RBHAs’
Intensive Case Management Teams
As of December 31, 2002
RBHA
High-Intensity,
Community-Based
Teams
Supportive
Treatment
Teams
CPSA-3 44
CPSA-5 188
NARBHA 128
PGBHA 46
ValueOptions 94 1,721
Total 500 1,721
Source: Auditor General staff analysis of RBHA program enrollment rosters as of
December 31, 2002.
Consumers showed modest improvement in functioning—On average,
consumers in the HB2003 intensive case management teams showed modest gains
(about two points) on five different dimensions of the Arizona Level of Functioning
State of Arizona
page 28
Table 7: Progress of HB2003 Intensive Case Management
and Comparison Group
by Performance Measure1
July 1, 2000 through January 31, 2003
Performance Measure
and Expected Outcome
ValueOptions
High-Intensity, Community-Based
Case Management Compared to
ValueOptions Comparison Group
Arizona Level of Functioning Assessment (ALFA)
Family, living environment (reduced symptoms)2 􀂀􈀠
Feeling, affect, mood (reduced symptoms) 􀂀􈀠
Role performance (reduced symptoms) 􀁼􇰠
Self-care (reduced symptoms)2 􀂀􈀠
Thinking, cognition (reduced symptoms) 􀂀􈀠
Clinical Global Impression (CGI)
Global improvement (reduced symptoms) 􀁼􇰠
Severity of symptoms (reduced symptoms) 􀁺􇨠
Hospitalization (reduced hospitalizations)
Rate of admissions 􀁺􇨠
Length of stay NA
Arrests (reduced arrests) 􀀹􃤠
SF-12 Health Survey (reduced symptoms)2 􀂀􈀠
Symbol key:
􀁺􇨠 Improved much more than comparison group
􀂀􈀠 Improved more than comparison group
􀁼􇰠 No difference between groups
􀀹􃤠 Did not improve as much as comparison group
􀂵􋔠 Worsened more than comparison group
NA not available
1 See Appendix 2, Tables 15, 17, 19, 20, and 23 (pages a-xxii through a-xxx) for detailed results on each measure.
Differences greater than 10 percent of the total available points on the measure (5 out of 50 for ALFA, 0.7 out of 7 for
CGI) are shown as improved much more than the comparison group. Differences that were not statistically significant
are shown as no difference between groups.
2 Not a performance measure identified by the Division and the RBHAs for intensive case management.
Source: Auditor General staff analysis of program outcomes and assessment and service encounter data provided by the
Division and the RBHAs for the period July 1, 2000 through January 31, 2003, for HB2003 consumers; and
assessment and service encounter data provided by BHS for the period January 1, 2000 through April 30, 2002,
for the comparison group.
Assessment (ALFA), while a comparison group of consumers either stayed the same
or worsened. As shown in Table 13 (see Appendix 2, page a-xx), consumers who
entered the program at the severe dysfunction level made greater gains, progress-ing
to the moderate dysfunction level after spending at least 6 months in the new pro-gram.
In contrast, consumers who entered at the moderate level showed less
improvement, and those who entered at the slight dysfunction level lost ground on
most measures. Table 14 (see Appendix 2, page a-xxi) shows results by RBHA for all
five ALFA dimensions.
Comparison group consumers lost ground on the ALFA measures, on average, while
some in the high-intensity case management teams remained stable and others
slightly improved. The comparison group consisted of ValueOptions consumers who
were eligible for high-intensity case management, but instead received traditional
case management during the time auditors studied. As shown in Table 15 (see
Appendix 2, page a-xxii), comparison group consumers whose ALFA scores started
in the severe dysfunction range showed some improvement. However, their scores
remained in the severe range. In contrast, consumers on the high-intensity teams
who started in the severe range moved to the moderate range.
Consumers stable on symptom severity—A measure of symptoms, the
Clinical Global Impression (CGI), showed mixed results on two dimensions—global
improvement and severity of symptoms. The CGI measures the effects of
psyghotropic medications, and is completed by the clinician who monitors consumer
medications. On the global improvement dimension, only CPSA-3 and CPSA-5
showed positive results, while PGBHA’s consumers lost ground. One RBHA,
ValueOptions, showed improvement on the severity of symptoms dimension, and
this improvement was greater for these consumers than for the comparison group.
However, only one other RBHA’s consumers showed improvement. Tables 16 and 17
(see Appendix 2, pages a-xxiii through a-xxiv) summarizes results of the CGI.
Consumers reported improvement on health survey and reduced or
stable arrests—Generally, consumers showed improvement on the health survey
and reduction or stability in arrest measures, although consumers in the comparison
group showed greater improvement in self-reported arrests. Specifically:
􀁺􇩈 Health survey shows consumers reported improvement—Most consumers par-ticipating
in intensive case management programs showed some improvement
in their mental health as measured by the SF-12 health survey. The SF-12 asks
consumers direct questions about their health status, so it reflects their own per-ceptions
rather than a clinician’s. For example, consumers indicate how often
emotional problems interfere with their daily life. Results of this measure indicate
that, on average, consumers in nearly all the intensive case management teams
reported better mental health functioning after participating in the program for at
least 6 months. As shown in Table 18 (see Appendix 2, page a-xxv), RBHAs
showed improvement on the health survey. Consumers in the comparison
Consumers rated at
severe dysfunction lev-els
at enrollment
improved to moderate
dysfunction after 6
months.
Office of the Auditor General
page 29
group did not make similar improvements, as shown in Table 19
(see Appendix 2, page a-xxvi).
Consumers interviewed during the audit also told auditors that
they felt the new services had helped them. For example, con-sumers
reported that the team helps them function well in the
community, provides them with opportunities to socialize, and
helps them with their daily living needs. One consumer, who is
depressed, has epilepsy, and is an alcoholic, reported that his
involvement with an intensive case management team saved his life. He lives
independently with the help of the intensive case management team and
attends chemical dependency classes. Case managers and other team staff
auditors interviewed reported that intensive case management services help
clients stabilize, gain a better understanding of their illness and its impact, and
gain a better understanding of their symptoms.
􀁺􇩒 Reduced or stable arrests—The Division and the RBHAs identified a reduction
in arrests as a performance measure for the intensive case management pro-grams.
Two of the four RBHAs were able to provide complete enough informa-tion
for analysis. Overall, the total number of consumers arrested and the num-ber
of arrests prior to participation in HB2003 programs is low. ValueOptions’
high-intensity case management consumers showed a reduction in the number
of consumers arrested, but the comparison group consumers showed a greater
reduction (see Table 20, Appendix 2, page a-xxvii). The number of consumers
arrested remained stable at CPSA-3 and CPSA-5. ValueOptions’ high-intensity
case management consumers showed a reduction in the total number of
arrests, as shown in Table 21 (see Appendix 2, page a-xxviii), although again
the comparison group showed a greater reduction than this group. Although
arrest data is self-reported, the comparison group’s better performance on this
measure suggests that the Division should work with the RBHAs to determine
why the HB2003 programs did not have a greater impact. As a followup to this
analysis, the Division should analyze arrests for all four RBHAs, since only two
of the four RBHAs had sufficient data to be included in this analysis. The Division
could do this as part of its planned evaluation.
Hospitalizations remained stable for most groups—Auditors examined
hospitalization in two ways: the number of consumers hospitalized, and hospitaliza-tion
rate (the number of hospitalizations per 100 consumers). The number of con-sumers
hospitalized remained unchanged for most RBHAs and for the comparison
group. One RBHA, NARBHA, showed an increase in the number of consumers hos-pitalized,
as shown in Table 22 (see Appendix, page a-xxix). The rate at which con-sumers
were hospitalized per 100 consumers remained unchanged for two of the
four RBHAs, while the comparison groups deteriorated, as shown in Table 23 (see
Appendix 2, page a-xxx). One RBHA, CPSA-5, showed an improvement in the hos-pitalization
rate, and NARBHA’s rate worsened.
Consumers report that
the intensive case man-agement
teams help
them function well in the
community.
State of Arizona
page 30
Case Example
K.S., a PGBHA consumer, is a senior citizen who
has significant health problems. High-intensity
case management services have helped her stabi-lize
her mood so that she is more active and better
able to care for herself.
Arrests are a rare event
among HB2003 con-sumers.
Auditors could not compare length of stay in the two time periods because hospital-ization
records in the later period were incomplete. Because reducing hospitalization
is an important goal for intensive case management programs, the Division should
evaluate the programs’ impact on length of stay once data regarding discharge
dates is complete. This could be done as part of the Division’s planned evaluation.
Length of time in program did not affect ALFA results—Consumer out-comes
did not consistently improve when consumers in intensive case management
programs for longer periods were compared to those in the programs for less time.
For example, consumers in the ValueOptions high-intensity case management
teams for 12 months showed improvement on all three ALFA dimensions identified
as performance measures. However, consumers who had been in the teams for 18
months had little to no change in their functioning, on average, from their functioning
prior to entering the program. In contrast, consumers on ValueOptions’ supportive
treatment teams showed about the same improvement in functioning whether they
had been in the program for 6, 12, or 18 months. Further, at NARBHA, only con-sumers
who had been in the program for 18 months showed improvement on two of
five measures.
There are several possible reasons why the length of time in HB2003 intensive case
management programs did not consistently affect consumer symptoms. For exam-ple,
for many disorders, the long-term goal of treatment is to prevent future recur-rences
of symptoms, according to the American Psychiatric Association.1 The
Division’s Chief of Clinical Services stated that due to the cyclical nature of mental ill-ness,
at many points in treatment, prevention of regression and promotion of stabil-ity
can be considered a positive outcome. Further, division and RBHA officials have
also suggested that since recovery is a cyclical process in which consumers often
fluctuate between getting better and worse, the results may be capturing a recovery
cycle. As time goes on and consumers fluctuate in their functioning, the gains fluc-tuate
as well.
One RBHA’s consumers showed no benefits from program–—One
RBHA, PGBHA, had almost no positive results for its consumers in any of the out-comes
measured. Specifically, except for those with severe dysfunction on the fam-ily
and living environment dimension, PGBHA’s consumers did not improve on any
of the five ALFA measures examined. Further, they showed no change on one CGI
dimension and a slight worsening on the other, had no change in their SF-12 health
survey results, and no change in their hospitalization rate.
Division and PGBHA officials could not explain this lack of success. PGBHA estab-lished
high-intensity case management teams similar to those at ValueOptions but
did not show similar results. Although the number of consumers included in the ALFA
analysis was relatively small, as only 22 PGBHA consumers met the inclusion crite-
1 Gabbard, Glen O., M.D., Editor-in-Chief, Treatments of Psychiatric Disorders. Third Edition, 2001.
Office of the Auditor General
page 31
ria for this analysis, other analyses with comparable or even smaller numbers of par-ticipants
showed results. PGBHA’s consumers did not differ from ValueOptions’
high-intensity case management team participants in the beginning level of severity.
In addition, although PGBHA experienced difficulty in meeting staffing standards,
other RBHAs had the same difficulties, yet their consumers showed improvement.
The Division should examine the causes for the lack of significant results for
PGBHA’s consumers. Again, the Division could do this as part of its planned pro-gram
evaluation.
Program design has some elements of successful
models
The Division and the RBHAs jointly developed guidelines for HB2003 intensive case
management programs, using other successful intensive case management models
as a guideline. Research has shown that intensive case management programs that
contain certain program elements are associated with positive consumer outcomes.
During the planning stages prior to implementing the HB2003 programs, the Division
formed a literature review group to analyze research on intensive case management.
The group, which included staff from the Division, CPSA, PGBHA, and ValueOptions,
researched various intensive case management models, such as Wisconsin’s
Program of Assertive Community Treatment (PACT), and recommended program
guidelines.1 According to division and RBHA officials, the review group selected what
they believed were the most critical elements of best practice programs for its rec-ommendations,
including guidelines for community-based treatment, staff-to-con-sumer
ratios, and staffing levels. Further, the review group developed program-spe-cific
checklists for monitoring how well the intensive case management programs
adhered to the guidelines.
The RBHAs and their providers chose to implement their programs in different ways,
with some adhering more closely to the PACT and similar models than others. For
example, CPSA adapted the PACT model by leaving out requirements for daily team
meetings and a minimum percentage of consumer contact occurring in the commu-nity
instead of at clinical facilities. PGBHA adopted a rural version of Wisconsin’s
model, which allows the use of alternatives for crisis service instead of team member
services outside of business hours. In addition, only two providers told auditors that
they require a minimum number of consumer contacts per week, a common require-ment
in other models, but omitted from the guidelines developed by the Division and
the RBHAs.
As the RBHAs monitored their intensive case management programs, they found
that the programs struggled with consistently meeting staffing-level guidelines.
Division and the RBHAs
analyzed research on
intensive case manage-ment,
and selected ele-ments
for its program
recommendations.
1 NARBHA staff did not participate in the review group, but modeled their program after a rural high-intensity case man-agement
program in South Carolina.
State of Arizona
page 32
However, as the results generally indicate, the RBHAs and providers have success-fully
used creative approaches to meet the spirit of the guidelines. For example, the
guidelines require intensive case management teams to have a master’s-level team
leader, but these positions have been vacant at some reviews due to staff turnover.
To fulfill the team leader staffing guidelines, one service provider hired a different
master’s-level staff to serve as a clinical consultant to the team. In another case, a
provider did not have a vocational rehabilitation specialist on its intensive case man-agement
team. To remedy the problem, the provider trained one of its existing staff
members to fill the position.
RBHAs plan to continue programs
The RBHAs plan to continue HB2003 case management programs but may have to
modify them. In addition, some new programs based on the HB2003 model have
been developed:
􀁺􇩃 Continuation of current programs—The RBHAs plan to continue most intensive
case management programs; however, some programs will be modified once
HB2003 funds are no longer available. Some RBHAs’ teams will operate with
decreased staffing levels. For example, ValueOptions plans to pay for most of
its 39 HB2003-funded staff positions through its general budget, which consists
of Medicaid and non-Medicaid monies, once HB2003 monies run out. However,
programs can use the infrastructure, such as transportation and training mod-ules
paid for with HB2003 funds, to continue offering a model similar to HB2003.
According to the RBHAs, providers plan to use other fund sources for continued
services to non-Medicaid consumers and continue billing Medicaid for con-sumers
who are eligible.
􀁺􇩄 Development of new programs—ValueOptions has expanded its high-intensity
case management program to two other service sites—one in Glendale and one
in Mesa. These programs are modeled after the HB2003 program, but serve
non-HB2003 consumers.
Based on the results of its analysis, the Division should develop recommendations
and provide technical assistance to the RBHAs to improve their intensive case man-agement
programs.
Most HB2003 case
management programs
will continue with modifi-cations.
Office of the Auditor General
page 33
Recommendations
1. The Division should conduct its own impact analysis of HB2003 intensive case
management services. Specifically, the Division should:
a. Analyze arrests for all RBHAs that developed intensive case management
programs since only two of four RBHAs had enough complete information
to include in the Auditor General’s analysis.
b. Evaluate the impact on length of hospital stay once the data regarding dis-charge
dates is complete enough for analysis.
c. Examine the causes for the lack of significant results for PGBHA’s con-sumers.
The Division could conduct these analyses as part of the program evaluation it
plans to conduct once the RBHAs spend all of their HB2003 monies.
2. The Division should develop recommendations and provide technical assis-tance
to the RBHAs to improve their intensive case management programs
based on the results of its research.
State of Arizona
page 34
Rehabilitation activities have increased
Three RBHAs report using HB2003 monies to provide higher levels of vocational
rehabilitation and recovery support services for promoting recovery and greater self-sufficiency.
RBHAs responded to HB2003’s requirement to expand these services in
two main ways—integrating these services into existing intensive case management
programs, and expanding providers and services in their regions. Increases in reha-bilitation
activities at ValueOptions and CPSA helped increase participation from
slightly more than 24 percent to 40 percent. The Division and the RBHAs plan to sus-tain
the enhanced services, which are now covered by Medicaid because of the
Covered Services Project’s implementation in October 2001.
Rehabilitation services cover a broad spectrum and
involve two agencies
Consistent with the HB2003 legislation, the Division’s plan specifications allowed the
RBHAs to propose using HB2003 monies for recovery support and rehabilitation pro-grams.
Using $5.4 million in HB2003 monies, or nearly 16 percent of
the total spending as of June 30, 2003, three RBHAs have provided
greater vocational rehabilitation and recovery support services for
consumers.1 Recovery support consists of any services intended to
help consumers make progress in their recovery and includes serv-ices
that help consumers live in the community. These community
support services include the intensive case management and med-ication
management services discussed in Finding 2 (see pages 25
through 34), as well as “peer support” and “friend advocacy” pro-grams
that recruit, train, and support people to provide advocacy,
friendship, and support to persons with serious mental illness.
Rehabilitation services are also a part of recovery support and
include a wide array of services. These services range from teaching
1 CPSA, NARBHA, and ValueOptions reported using HB2003 monies for rehabilitation services to support the strategies
discussed. PGBHA used non-HB2003 resources to integrate rehabilitation into its HB2003 case management teams. The
fifth RBHA, Excel, reported that it used all its HB2003 monies for its housing programs and transportation.
Office of the Auditor General
FINDING 3
page 35
Recovery
Process helping people to participate
fully in their community despite their
disability. Care focuses on increasing
consumers’ ability to successfully
cope with life’s challenges, facilitating
recovery, and building resilience, not
just managing symptoms. Consumers
and their families have meaningful
choices about services and providers.
consumers basic community living skills, such as acquiring and developing the skills
necessary to manage a home or provide for basic daily living needs, to helping them
prepare to find and keep a job. Rehabilitation services may include encouraging con-sumers
to get involved in volunteering and other community activities such as clubs,
churches, and community organizations. They may also include attending club-houses
and consumer-run drop-in centers where consumers can meet to support
each other and socialize, volunteer, engage in transitional work activities or regular
employment, and actually oversee operations.
Rehabilitation services also include vocational rehabilitation services such as voca-tional
assessment, counseling, and job placement. These services involve the
Department of Economic Security’s Rehabilitation Services Administration (RSA). A
1993 interagency agreement facilitates the partnership between the Division and
RSA and sets forth the agencies’ contractual obligations. Under this agreement, the
behavioral health system provides rehabilitation services, including psychosocial
rehabilitation such as living skills, training, and clubhouses; consumer-operated serv-ices;
supported education; and extended supported employment. RSA provides
vocational assessment services such as career exploration, career-directed educa-tion
services, and employment-directed services per its federal mandate.1 For con-sumers
who are interested in RSA services, the two agencies combine resources
every year to leverage federal monies and provide career exploration, career-related
education, job placement, and other employment-related services. RSA can obtain
nearly $4 from federal funding for every $1 the Division contributes. In fiscal year
2003, the Division contributed more than $1.7 million in state monies of the RSA’s
nearly $8.2 million budget. Under the agreement, RSA agrees to use these combined
monies to develop and implement contracts with community providers to meet the
vocational needs of contracts to persons with serious mental illness. CPSA also com-bined
a portion of its HB2003 allocation with RSA federal monies to provide service
providers in Southern Arizona with RSA grants to establish new employment pro-grams.
RBHAs integrate and expand services
The RBHAs mainly pursued two strategies for improving rehabilitation and recovery
support services for their consumers: integrating rehabilitation planning into clinical
case management and expanding rehabilitation services availability in their respec-tive
geographic service areas. In addition, the Division and RSA have worked togeth-er
to promote recovery principles in rehabilitation service planning.
Rehabilitation integrated into intensive case management—To increase
consumers’ participation in rehabilitation activities, the RBHAs integrated rehabilita-tion
services into treatment planning for consumers who participate in intensive case
management teams. At three RBHAs—CPSA, PGBHA, and ValueOptions—rehabili-
Rehabilitation services
include more than voca-tional
training.
1 RSA is federally mandated to provide vocational services to persons with disabilities, including persons with serious men-tal
illness, in accordance with the Federal Rehabilitation Act of 1973.
State of Arizona
page 36
tation specialists or vocational specialists were placed as members of the case man-agement
teams. According to NARBHA officials, its teams rely on vocational spe-cialists
at provider agencies. Integrating rehabilitation and vocational staff into the
clinical treatment team is consistent with literature on high-intensity case manage-ment
models, which recommends including these positions as part of the treatment
team. The specialists help consumers identify their interests and encourage con-sumers’
participation in rehabilitation programs. They also refer consumers to RSA
and work with RSA’s vocational counselors for consumers who are interested in
seeking employment.
Range of providers and services expanded—Three RBHAs—
ValueOptions, NARBHA, and CPSA—report using HB2003 monies to expand the
array of rehabilitation services available in their regions. These efforts are consistent
with recovery principles calling for consumers to be able to choose from a variety of
services, activities, and programs as part of their treatment. Specifically:
􀁺􇨠 Expanded rehabilitation provider network in Maricopa County—In accordance
with the court-approved plan under Arnold v. Sarn, ValueOptions used HB2003
monies to expand the number of rehabilitation providers under contract.
ValueOptions originally had two providers, but was able to fund six more start-ing
July 1, 2001. One of the initial service providers—TripleR Behavioral Health—
operated two clubhouses in Maricopa County and provided supported employ-ment
services. The other provider offered work adjustment services. According
to ValueOptions’ officials, the expanded provider network allowed it to provide
additional rehabilitation and recovery support services such as home manage-ment
skills training, recovery training, work exploration, an “Art Awakenings” pro-gram,
supported education, and employment support services. ValueOptions
also used HB2003 monies to develop a new consumer-run drop-in center in
North Phoenix and enhance programs and facilities at existing drop-in centers.
Auditors were unable to identify how many people were involved in activities
prior to the HB2003 program because the Division did not require the RBHAs to
collect this information until April 2001. However, as of October 7, 2002,
ValueOptions reported that more than 3,700 of its nearly 14,000 enrolled mem-bers
were involved in some type of rehabilitation activity.
􀁺􇨠 New network of centers in Northern Arizona—NARBHA reported that
it used HB2003 monies to open the first consumer-operated recovery
centers in its service area. In partnership with RSA, NARBHA estab-lished
a network of five recovery centers under an organization called
NAZCARE (Northern Arizona Consumers Advancing Recovery and
Empowerment) headquartered in Prescott. According to NARBHA
officials, the first center, New Hope Recovery Center in Prescott,
opened in January 2002, and the remaining four opened between
January 2002 and October 2002.1 NAZCARE, a private, nonprofit
community service agency certified by ADHS, employs consumers to
Rehabilitation specialists
help consumers identify
their interests in avail-able
programs.
Office of the Auditor General
page 37
New Hope Recovery Center, Prescott, Arizona
1 According to NARBHA and NAZCARE officials, one drop-in center based in Snowflake, Arizona, closed in October 2003.
manage the centers and offer peer support. HB2003 dollars
funded staffing, training, operations, and facility development.
At these centers, consumers can socialize, work as managers
or peer specialists, and develop friendships and a support net-work.
NARBHA reports that close to 200 persons were involved
in the NAZCARE Centers during August and September 2003.
As of September 22, NAZCARE reported employing a total of
13 consumer staff, and expected to hire 5 more people to fill 18
total available positions.
􀁺􇩅 Enhanced consumer-run services and vocational system
evaluation in Southern Arizona—CPSA reported that it used
HB2003 monies to purchase computers and improve facilities
at two consumer-run clubhouses in Pima County. CPSA staff
indicated they also provided technical assistance and guidance
to the clubhouses to help them obtain status as community service agencies
that can bill services to Medicaid. CPSA also reported using HB2003 monies to
conduct a vocational system evaluation. CPSA initially contributed part of its
HB2003 monies to RSA to provide Southern Arizona service providers with RSA
grants for new employment programs. When RSA could not match HB2003
monies because of financial difficulties, they returned the unmatched monies to
CPSA. CPSA and RSA subsequently used these monies to hire a consultant to
assess the effectiveness of the rehabilitation service system in CPSA’s two geo-graphic
service areas. The consultant assessed the system’s strengths and
identified areas for improvement in policy, practice and program design, and
staff development. To continue these efforts, CPSA offered a training conference
in March 2004 and plans an ongoing system evaluation. CPSA hopes these
activities will help the region address the problems identified and improve serv-ice
delivery.
Division and RSA promote recovery principles—Two RBHAs are working
with the Division and RSA to teach consumers recovery principles, train them in dif-ferent
recovery strategies, and help them find employment as peer support special-ists.
Both NARBHA and ValueOptions are working with RSA to train consumers as
peer support specialists. These specialists are trained to teach recovery principles
and strategies, such as how to develop Wellness Recovery Action Plans (WRAP), a
recovery tool developed by Mary Ellen Copeland, a national expert in recovery for
persons with serious mental illness. Both RBHAs reported using HB2003 funding to
train clinicians and consumers in WRAP and other strategies designed to promote
recovery and self-sufficiency. Their service providers have also hired consumers who
have been trained as peer support specialists. For example, some service providers
have hired consumers to answer phone calls via warm lines, an alternative to a cri-sis
hot line.
State of Arizona
page 38
The Division, RBHAs,
and RSA help train con-sumers
to work as peer
support specialists.
Case example
L.B., a 59-year-old woman who is diagnosed with
schizophrenia, reported that she spent an entire year
in a psychiatric health facility and underwent elec-troshock
therapy prior to entering the HB2003 pro-gram.
Through a new recovery model program that
NARBHA established with HB2003 funding, L.B.
attended WRAP training. New Hope Recovery Center
in Prescott hired L.B. in June 2002 to offer peer sup-port
services for other consumers. Her symptoms
have greatly diminished, and she has not returned to
the psychiatric facility.
Division monitors programs against standards—The Division and the
RBHAs developed a core set of standards for each type of rehabilitation program,
based on a review of best practices. For example, they developed guidelines for the
clubhouse programs based in part on standards established by the International
Center for Clubhouse Development, located at the Fountain House clubhouse in
New York City. Two RBHAs—ValueOptions and NARBHA—reported monitoring their
subcontractors through such activities as site visits, clinical record reviews, interviews
with program managers, and interviews with consumers. The Division reviewed and
approved the RBHAs’ monitoring plans, including a checklist the RBHAs use to mon-itor
the ongoing adherence to the guidelines. CPSA reported monitoring its HB2003
rehabilitation activities in a different manner. For example, instead of conducting
fidelity site visits at the two clubhouses that received HB2003 support, CPSA staff
provided technical assistance to these two agencies, as noted previously. In addition,
CPSA reported that its vocational system evaluation far exceeds the Division’s fideli-ty
requirements.
Some participation in meaningful activities increased
Consumers in two RBHAS’ HB2003 programs increased their involvement in some
types of meaningful rehabilitation activities.1 Many people with serious mental illness
often have nothing meaningful to do during the day—they do not socialize with oth-ers,
attend school, or go to work. Thus, one important goal of the RBHAs’ rehabilita-tion
efforts under HB2003 was to increase their consumers’ activity levels.
Consumers at ValueOptions increased their participation in psychosocial and con-sumer-
run activities during the period auditors examined. State-wide, consumers
involved in these activities improved their interpersonal relations functioning as meas-ured
by the ALFA. Both CPSA-5 and ValueOptions’ consumers showed increased
participation in education, training, and transitional work
activities. Most consumers showed little or no increase in
paid employment, which may in part be due to RBHAs
placing greater emphasis on getting people involved in any
meaningful activity. A recent ValueOptions study found
HB2003 participants were more involved in meaningful
rehabilitation activities than other consumers, especially
psychosocial rehabilitation activities. Since gains did not
occur across all RBHAs, the Division should analyze reha-bilitation
activities at a later date, particularly the activity lev-els
at NARBHA and PGBHA. The Division could conduct
this follow-up analysis as part of its planned HB2003 eval-uation.
1 The evaluation time frame for rehabilitation services spanned 20 months from June 1, 2001 through January 31, 2003.
Auditors used a shorter time frame to control for the effect of a data conversion that occurred in April 2001, which
changed the way the RBHAs reported rehabilitation status.
Office of the Auditor General
page 39
Case Example
J.S., a ValueOptions consumer in his early 40s,
moved out of a supervisory care home into
HB2003-supervised housing. A shy, reserved
man with schizoaffective disorder, J.S. went
through the WRAP training and now takes the bus
to visit the TripleR clubhouse in central Phoenix.
J.S. is very happy with his clinical team and likes
the clubhouse because of all the friends he has
made. He has also expressed interest in learning
about computers.
Increase in meaningful activities varies by type of activity—More con-sumers
became involved in activities classified as psychosocial rehabilitation and
consumer-run services than in education, training, or transitional work activities, and
full- or part-time employment. Specifically,
􀁺􇩉 Involvement in psychosocial rehabilitation and consumer-run activities
increased—HB2003 program participants at CPSA-5, NARBHA, and
ValueOptions increased their involvement in activities intended to improve
socialization and interpersonal functioning.1 These include social rehabilitation,
skills training, clubhouse programs, volunteer work, and consumer-run drop-in
centers (see Appendix 2, Table 24, page a-xxxi). Consumers at CPSA-5 and
ValueOptions who were involved in psychosocial and consumer-run activities
improved in their interpersonal relations functioning after spending at least 180
days in HB2003 programs. (See Appendix 2, Table 25, page a-xxxiii).
􀁺􇩌 Limited increase in education, training, and transitional work activities—
Consumers on CPSA-5’s high-intensity case management teams and those in
ValueOptions traditional case management increased their participation in edu-cation,
training, and transitional work activities, as shown in Table 26 (see
Appendix 2, page a-xxxiii). At CPSA-5, the number of consumers involved in
these activities was relatively high before HB2003, and doubled, with its con-sumers
most often entering transitional employment programs. ValueOptions
invested HB2003 monies directly in supported education services, which offer
financial assistance for community college courses, GED preparation, and other
education. ValueOptions offered the services to all consumers, including those
participating in high-intensity, supportive treatment, and traditional case man-agement
teams.
􀁺􇩌 Little or no change in employment—State-wide, the number of consumers
employed either full- or part-time remained low during the period examined.
Only ValueOptions’ supportive treatment teams showed an increase in employ-ment
(see Appendix 2, Table 27, page a-xxxiv). According to the Division, the
HB2003 programs focused primarily on those individuals who were not express-ing
an immediate desire to enter the workforce. As the RBHAs expanded their
rehabilitation services, they emphasized getting people involved in any mean-ingful
activity, rather than focusing exclusively on paid employment. Although
other rehabilitation activities may benefit a person’s recovery, research suggests
that they may not directly lead to paid employment. Paid employment is the
highest level of independence, but moving people with serious mental illness
toward greater self-sufficiency may not move them toward paid employment
unless paid employment is a designated treatment or program goal. If compet-itive
employment is the ultimate goal, research on the employment of persons
with serious mental illness states that efforts should be focused on this specific
goal to achieve a successful outcome.
1 Although CPSA-5 and NARBHA showed statistically significant increases in participation, the actual number of con-sumers
involved—only 11 between both RBHAs—is too small to be meaningful when the total number of consumers for
those RBHAs is considered.
State of Arizona
page 40
Research also suggests that rapid placement in competitive employment and
providing time-unlimited, supported employment services is the most effective
strategy for improving employment outcomes, although more research is rec-ommended.
Federal law defines supported employment services as ongoing
support services and other appropriate services needed to support and main-tain
an individual in competitive work in integrated work settings.
In addition to analyzing consumers’ rehabilitation activity status at the time of assess-ment,
auditors also interviewed consumers who told auditors how the activities have
helped them. For example, consumers at a CPSA clubhouse in Tucson said volun-teering
at the clubhouse helped them feel needed and that the clubhouse could not
be run without them. The clubhouse director explained that the consumers were
building skills and learning to engage with the community. In addition, auditors inter-viewed
four Arizona State Hospital patients who spend part of their days in a
ValueOptions’ work program. One said, “They gave me something to concentrate
on, they gave me hope.” Another ValueOptions consumer said her job at a thrift store
is the first job she has had, and it helps her to be proud and build her self-esteem.
ValueOptions study found similar results—In October 2002, ValueOptions
compared activity and employment levels among consumers at its 21 clinical sites.
This research found higher rehabilitation activity levels at the three HB2003 sites
when compared to the other 18 sites, especially in the psychosocial rehabilitation
activity category.
ValueOptions officials attributed some of the consumers’ increased participation lev-els
to higher rehabilitation specialist staffing. According to ValueOptions, as of
August 2003, each clinical team at the HB2003 sites had a rehabilitation specialist,
for a total of 13 specialists available to consumers at those three sites. In contrast,
ValueOptions reported 20 total positions across 18 non-HB2003 sites, with most sites
employing just one rehabilitation specialist and two sites with no rehabilitation spe-cialist
at all. One of the plaintiffs’ attorneys in Arnold v. Sarn identified the addition of
rehabilitation specialists at ValueOptions as one of the most positive changes in
years.
The Division should analyze activity levels among RBHAs—Although
overall a